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RK301  B27  1 901     Oral  pathology  and  p 


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Oral  Pathology 

and  Practice. 


^  TEXT- BOOK  FOR  THE  USE  OF  STUTiENTS  IN 

DENTAL  COLLEGES  AND  A  HAND-BOOK 

FOR.  DENTAL  PRACTITIONERS. 


BY 
W.  C.  BARRETT,  M.D.,  D.D.S.,  M.D.S.,  LL.D., 

Professor  of  the  Principles  and  Practice  of  Dentistry  and  Oral  Pathology  in  the  University  of 

Buffalo  Dental  Department ;  Professor  of  Dental  Anatomy  and  Pathology  in  the  Chicago 

College  of  Dental  Surgery ;  Late  Professor  of  Oral  Pathology  in  the  University 

of  Buffalo  Medical  Department;  Consulting  Oral  Surgeon  to  the  Buffalo 

General  Hospital,  etc.,  etc. 


SECOND  EDITION, 

Revised,  Enlarged,  and  Illustrated. 


PHILADELPHIA: 

THE  S.  S.  WHITE  DENTAL  MFG.  CO. 

1901. 


Copyright,   1898,   by  W.  C.  Barrett. 
Copyright,  1901,  by  W.   C.   Barrett. 


■RK50 


TO 
My   beloved    Associates    in    College    "Work, 

AND   TO 

My    Boys, 

THE   MEMBERS  OF   THE   VARIOUS    CLASSES  WHO    HAVE 

BEEN  UNDER  MY   INSTRUCTION,   AND  WHOM 

I    HAVE   SOUGHT   TO   SERVE, 

THIS  WORK 
IS   AFFECTIONATELY  INSCRIBED. 


PREFACE    TO    SECOND    EDITION. 


The  kind  reception  accorded  the  first  edition  of  this  book  by 
the  dental  profession  was  a  matter  of  almost  as  great  surprise  as- 
gratification.  The  author  did  not  anticipate  that  within  two  years 
it  would  be  exhausted,  and  a  second — which  is  greatly  belated — 
demanded,  for  works  of  this  kind  do  not  appeal  to  the  general 
public  and  are  restricted  in  their  sale. 

At  the  outset  the  publishers  strongly  urged  that  the  text  be 
properly  illustrated  with  cuts,  but  the  author  had  not  sufficient  faith 
in  his  venture  to  increase  the  necessary  cost  of  the  book  by  the 
addition.  The  fact  that  those  interested  have  generally  approved 
his  efforts  leads  him  to  put  forth  yet  greater  exertions  to  make  the 
volume  more  worthy  their  confidence. 

Accordingly  it  has  been  thoroughly  revised,  not  a  chapter  now 
reading  as  it  did  originally,  while  much  new  matter  has  been  added 
and  many  illustrations  have  been  introduced,  the  principal  ones 
being  original  with  this  work.  The  author  has  endeavored  to  profit 
by  the  honest  criticisms  of  the  reviewers  of  the  first  edition,  and 
sincerely  hopes  that  some  of  its  faults  have  been  eliminated. 

He  offers  this  riper  fruit  in  the  hope  that  it  will  not  only  be- 
more  palatable  and  easy  of  digestion  than  that  which  was  plucked" 
earlier,  but  that  it  will  also  prove  nutritious  and  professionally 
healthful.  He  trusts  he  may  not  be  thought  presumptuous  when 
he  commends  it  to  the  student  as  a  text-book,  to  the  teacher  as  a- 
help  in  his  arduous  duties,  and  to  the  practitioner  as  a  work  for 

daily  reference. 

W.  C.  B. 

208  Franklin  St.,  Buffalo,  N.  Y., 
October,  igoo. 


Yl  PREFACE    TO    FIRST    EDITION. 


PREFACE   TO   FIRST   EDITION. 

This  book  is  not  a  treatise,  and  surgical  or  operative  pro- 
cedures form  no  part  of  its  scheme.  In  writing  it  the  first  object 
has  been  to  condense,  not  to  ampHfy,  that  it  may  be  pubHshed  at  as 
low  a  price  as  possible.  With  this  end  in  view,  cuts  have  been 
excluded,  desirable  as  they  might  in  some  instances  be.  The 
work  has  thus  been  kept  within  the  limits  of  a  manual. 

It  has  been  the  aim  of  the  author  to  consider  as  succinctly  as 
is  consistent  with  clearness  the  functional  derangements  of  all  the 
oral  tissues  that  properly  fall  within  the  compass  of  a  broad  dental 
practice.  In  addition  to  this  there  are  certain  constitutional  dis- 
orders, the  effects  of  which  may  be  observed  in  and  about  the  oral 
cavity,  which  have  not  as  yet  been  incorporated  into  our  specialty, 
and  perhaps  never  will  be,  but  of  which  it  is  essential  that  the 
dentist  should  have  sufficient  knowledge  to  enable  him  to  make  a 
clear  diagnosis,  even  if  he  should  not  purpose  active  remedial 
measures.  Such  disorders  as  facial  paralysis,  syphilis,  and  tumors 
have  therefore  been  given  a  general  consideration,  but  practitioners 
who  wish  to  make  a  more  exhaustive  study  of  those  subjects  are 
referred  to  special  works  upon  them. 

It  should  not  be  expected  that  a  writer  will  blindly  and 
unreservedly  follow  even  accepted  practice  when  in  his  opinion  it 
is  founded  in  error;  such  a  course  would  make  of  him  a  mere  echo, 
and  would  inhibit  originality  and  progress.  If,  therefore,  the 
author  has  advanced  his  own  ideas  upon  subjects  concerning  which 
there  is  a  difference  of  opinion,  he  believes  them  entitled  to  candid 
consideration  in  the  light  in  which  they  are  presented.  If  not 
found  in  harmony  with  clinical  experience  and  observation,  they 
disprove  themselves. 

It  is  only  within  a  few  years  that  Pathology  as  a  separate  study 
has  been  made  a  distinct  part  of  the  curriculum  of  our  colleges. 
The  treatment  of  a  few  of  the  more  pronounced  pathological  condi- 
tions has  always  been  included  in  the  course  of  lectures  upon 
Operative  Dentistry,  or  in  that  of  Materia  Medica  and  Therapeu- 
tics, but  the  subject  has  been  made  rather  incidental  than  founda- 
tional.    With  the  growth  of  dental  practice  and  the  expansion  of 


PREFACE    TO    FIRST    EDITION'.  Vll 

the  course  of  instruction  in  our  colleges,  a  more  extended  con- 
sideration of  the  treatment  of  complications  naturally  attendant 
upon  dental  degenerations  becomes  a  necessity  in  our  best  schools. 
Dentists  are  reasonably  plentiful,  and  the  multiplication  of  institu- 
tions devoted  to  their  training  is  believed  to  promise  an  even 
more  abundant  supply.  The  complaint  that  the  profession  is 
getting  uncomfortably  crowded  arises  from  the  old  graduates,  as 
well  as  from  those  who  have  been  deprived  of  the  advantages  of 
scholastic  training. 

The  remedy  for  these  conditions  can  only  be  found  in  the 
deepening  of  the  stream — in  the  enlarging  of  the  field  of  practice 
by  incorporating  with  the  methods  of  the  past  (the  mechanical 
and  operative  procedures  which  have  already  been  carried  to  such 
a  high  state  of  perfection)  the  treatment  of  the  diseases  that  prop- 
erly fall  within  the  province  of  the  oral  physician,  and  the  making 
of  Oral  Practice  a  true  specialty  of  medicine. 

For  some  years  the  author  has  annually  delivered  before  his 
classes  in  dental  colleges  from  fifty  to  sixty  lectures  upon  patho- 
logical and  morbid  functional  and  structural  conditions  in  the  oral 
cavity  and  the  tissues  immediately  connected  with  it,  in  which  there 
has  been  attempted  nothing  of  instruction  in  constructive,  opera- 
tive, or  manipulative  dental  work.  This  has  tended  to  open  for 
students  a  field  insufficiently  cultivated  by  dentists.  It  has  en- 
larged their  opportunities,  added  to  their  emoluments,  and  given  to 
them  a  better  professional  status. 

But  in  this  line  of  teaching  he  has  been  seriously  handicapped 
by  the  absence  of  proper  text-books.  Excellent  treatises  were  in 
existence,  but  none  of  them  was  exclusively  devoted  to  the  every- 
day work  of  either  student  or  practitioner.  They  included  other 
branches  of  dental  science,  and  while,  as  works  of  reference  and  as 
text-books  for  advanced  members  of  the  profession  who  desired 
to  make  special  studies  in  scientific  fields,  they  were  much  better 
adapted  than  a  work  of  this  kind  can  possibly  be,  yet  as  hand- 
books for  students  in  colleges  and  as  everyday  manuals  for  those 
who  sought  help  in  the  hourly  recurring  complications  of  office 
life  they  were  too  voluminous. 

In  the  time  of  Hippocrates  it  was  possible  to  comprise  in  one 
volume  all  that  was  known  of  medicine.  ]\Iany  of  our  older 
practitioners  can  call  to  mind  the  days  when  the  whole  art  of  den- 


Vlll  PREFACE   TO    FIRST    EDITION. 

tistry  was  imparted  by  a  preceptor  in  a  few  easy  lessons.  One 
man  might  then  be  universally  recognized  as  the  highest  authority 
in  the  whole  field.  Now,  a  complete  knowledge  of  any  one  of  the 
distinct  branches  of  medicine  demands  a  post-graduate  course  after 
four  years  of  general  study,  while  three  years  in  a  dental  college 
are  scarce  sufficient  to  enable  the  student  to  master  the  basal 
principles  of  our  greatly  extended  oral  practice.  Not  alone  medi- 
cine, but  dentistry  is  divided  into  specialties,  and  already  there  are 
among  us  those  who  give  their  exclusive  attention  to  Operative  or 
to  Prosthetic  work,  to  Oral  Surgery,  to  Odontothorsis  or  to 
Odontotherapy.  The  tendency  seems  to  be  toward  the  teaching 
of  each  branch  in  separate  classes,  with  distinct  text-books  for  the 
several  departments.  The  present  work  grew  out  of  that  seeming 
drift,  and  the  germ  of  its  existence  lay  in  the  notes  of  lectures  upon 
the  subjects  considered. 

The  book  could  easily  have  been  expanded  into  greater  dimen- 
sions, but  that  would  have  limited  its  usefulness  among  those  for 
whom  it  was  specially  prepared.  Extended  abstracts  of  the  writ- 
ings of  others  might  have  been  included  with  profit,  but  that  would 
have  swollen  the  volume  beyond  the  limits  set  for  it,  and  have 
added  to  its  cost.  Besides,  a  book  should  have  a  distinctive  indi- 
viduality, a  personality  as  pronounced  as  that  of  the  successful 
teacher,  and  without  this  it  is  usually  as  insipid  as  is  the  man  or 
woman  who  possesses  no  distinguishing  peculiarities.  So  it  is 
perhaps  better  that  it  should  be  marred  by  some  of  the  many  faults 
of  its  author  rather  than  be  without  any  special  traits  at  all. 

W.  C.  B. 


CONTENTS. 


CHAPTER  I.  PACE 

General  Considerations i 

CHAPTER  H. 
Bacteriology  :  Classification   3 

CHAPTER  HI. 
Fermentation    9 

CHAPTER  IV. 
Bacteriological  Pathology 14 

CHAPTER  V. 
Septic  and  Aseptic  Conditions 18 

CHAPTER  VI. 
Inflammation  :  Its  General  Characteristics 25 

CHAPTER  VII. 

Changes  Attending  the  Inflammatory  Condition 32 

CHAPTER  VIII. 
Further  Degenerative  Changes T)! 

CHAPTER  IX. 
The  Products  of  Inflammation 40 

CHAPTER  X. 
General  Treatment  of  Inflammation 47 

CHAPTER  XI. 
Diseases  of  the  Gums 50 

CHAPTER  XII. 
Stomatitis 54 

CHAPTER  XIII. 
Treatment  of  Stomatitis 57 

CHAPTER  XIV. 
Pharyngitis  and  Tonsillitis 61 

CHAPTER  XV. 
Diseases  of  the  Tongue 64 

CHAPTER  XVI. 

Dentition  :  General  Considerations (yj 

ix 


X  CONTENTS. 

CHAPTER  XVII. 

PAGE 

The  Diseases  of  Dentition 71 

CHAPTER  XVIII. 
The  So-Called  Diseases'of  Dentition. 74 

CHAPTER  XIX. 
Treatment  of  the  So-Called  Diseases  of  Dentition 81 

CHAPTER  XX. 
The  Real  Diseases  of  Dentition 84 

CHAPTER  XXI. 
Dental  Caries   87 

CHAPTER  XXII. 
The  Pathology  of  Dental  Caries 94 

CHAPTER  XXIII. 
The  Medicinal  Treatment  of  Dental  Caries 99 

CHAPTER  XXIV. 
Pulpitis — Inflammation  of  the  Dental  Pulp 102 

CHAPTER  XXV. 
Treatment  of  Inflammatory  Conditions  of  the  Dental  Pulp 107 

CHAPTER  XXVI. 
Pericementitis — Inflammation  of  the  Peridental  Membrane iii 

CHAPTER  XXVII. 
Alveolar  Abscess  ii7 

CHAPTER  XXVIII. 

Symptomatology  and  Treatment  of  Alveolar  Abscess 128 

CHAPTER  XXIX. 
Deposits  upon  the  Teeth 135 

CHAPTER  XXX. 
Pyorrhea  Alveolaris I4i 

CHAPTER  XXXI. 
Pyorrhea  Alveolaris   (Continued) I44 

CHAPTER  XXXII. 
Facial  Neuralgias 15° 

CHAPTER  XXXIII. 
Facial   Paralysis    ^54 

CHAPTER  XXXIV. 
Sympathetic  Disturbances  ^5° 


CONTENTS.  XI 

CHAPTER  XXXV.  p^^.^ 

Diseases  of  the  Maxillary  Sinus i6i 

CHAPTER  XXXVI. 
Treatment  of  Diseases  of  the  Maxillary  Sinus 167 

CHAPTER  XXXVn. 
Diseases  of  the  Frontal  Sinus 172- 

CHAPTER  XXXVni. 
Cysts  and  Their  Treatment 175 

CHAPTER  XXXIX. 
Tumors  and  Neoplasms 182- 

CHAPTER  XL. 
Tumors  and  Neoplasms   (Continued) 185 

CHAPTER  XLI. 
Osteitis i9<? 

CHAPTER  XLII. 
Caries  of  Alveolar  Bone 194 

CHAPTER  XLIII. 
Necrosis  198^ 

CHAPTER  XLIV. 
Treatment  of  Necrosis 202' 

CHAPTER  XLV. 
Hypersensitive  Dentine 205 

CHAPTER  XLVI. 
Treatment  of  Hypersensitive  Dentine 210 

CHAPTER  XLVII. 
Secondary  Dentine,  Pulp  Nodules,  and  Calcifications 216 

CHAPTER  XLVIII. 

HyPERCEMENTOSIS 222 

CHAPTER  XLIX. 
Discolored  Teeth 225 

CHAPTER  L. 
Congenital  Imperfections  of  Enamel 227 

CHAPTER  LI. 

Acquired  or  Accidental  Imperfections  of  Enamel 233 

CHAPTER  LII. 
Replantation  ;  Transplantation  ;  Implantation 22,^ 


Xll  CONTENTS. 

CHAPTER  LIII.  p^gg 

Syphilis  :  General  Considerations 246 

CHAPTER  LIV. 
Syphilis  :  The  Primary  Stage 250 

CHAPTER  LV. 
The  Secondary  Stage  of  Syphilis 255 

CHAPTER  LVI. 
Tertiary  and  Hereditary  Syphilis 259 

CHAPTER  LVn. 
Syphilis  of  the  Mouth  and  Tongue  :  Recapitulation 265 

CHAPTER  LVIH. 
Physical  Diagnosis 268 

CHAPTER  LIX. 
Physical  Diagnosis  (Continued)  :  The  Respiration 273 

CHAPTER  LX. 
The  Oral  Tissues  in  Diagnosis 279 

CHAPTER  LXI. 
Wounds  and  Injuries 282 

CHAPTER  LXII. 
Treatment  of  Wounds 285 

CHAPTER  LXHI. 
Excessive  Bleeding  290 

CHAPTER  LXIV. 
Fractures  and  Their  Treatment 293 

CHAPTER  LXV. 
Special  Cases  of  Fracture 299 

CHAPTER  LXVI. 
Dislocations  and  Sprains 303 

CHAPTER  LXVII. 
Shock — Collapse 307 

CHAPTER  LXVHI. 
Treatment  of  Shock  , , , 310 


ORAL  PATHOLOGY  AND  PRACTICE. 


CHAPTER  I. 

GENERAL  CONSIDERATIONS. 

The  study  of  disturbed,  as  well  as  of  normal  systemic  co-idi- 
tions,  necessarily  commences  with  the  consideration  of  Function. 

Health  and  sickness  (ease  and  dis-esise)  are  dependent  upon  the  ac- 
tivities of  the  organs  of  the  body.  In  the  former  condition  all  are 
harmoniously  working  together,  each  accomplishing  its  proper 
task  in  the  best  manner  and  at  the  right  moment.  In  the  latter 
there  is  a  disturbance  of  the  interdependent  bodily  relations  through 
the  inaction  or  the  mal-action  of  some  organ  or  set  of  organs,  in- 
duced by  malnutrition,  by  unsanitary  conditions,  or  by  external  in- 
terference. 

Function  is  the  action  of  an  organ,  or  of  a  complete  set  of 
organs.  The  function  of  digestion  implies  the  proper  action  of  all 
the  organs  of  the  digestive  tract,  and  the  perfect  accomplishment  of 
this  requires  that  each  of  them  shall  be  in  that  state  of  health  which 
is  secured  only  by  the  normal  action  of  all  combined.  The  function 
of  every  organ  is  in  some  way  dependent  upon  that  of  others,  and  a 
state  of  complete  bodily  health  implies  perfectly  harmonious  rela- 
tions in  all  its  different  parts. 

The  function  of  insalivation  demands  that  all  of  the  salivary 
glands  shall  be  in  a  normal  condition,  secreting  healthy  saliva, 
and  that  the  saliva  shall  be  properly  mixed  with  ingested  food. 
The  secretion  of  the  mucous  glands  is  viscid  and  contains  mucin; 
that  of  the  parotid  is  largely  serous  and  contains  ptyalin,  while 
that  of  the  submaxillary  and  sublingual  glands  is  mixed  in  char- 
acter. Unless  all  these  secretions  are  combined  the  saliva  will 
lack  some  ingredient,  and  cannot  perfectly  perform  its  office.  If, 
then,  the  action  of  any  gland  is  not  normal  the  saliva  is  modified, 
and  this  may  interfere  with  the  function  of  digestion,  proper  assimi- 

2  I 


2  ORAL    PATHOLOGY    AND    PRACTICE. 

lation  may  be  inhibited,  every  tissue  of  the  body  may  lack  nourish- 
ment, and  thus  from  a  disturbance  in  one  apparently  unimportant 
organ  every  other  in  the  system  may  suffer. 

Physiology  is  the  science  of  normal  function.  Its  proper 
study  demands  a  knowledge  of  the  structure  of  the  organs  con- 
cerned. It  is  not  confined  to  man,  or  even  to  animal  life.  Wher- 
ever there  is  vitality,  growth,  organs  (that  is,  in  all  organic  matter) 
there  are  certain  laws  that  govern  the  functional  activity  of  the 
organism,  and  the  study  of  these  laws  is  called  Physiology. 

Physiology  is  divided  into  animal  and  vegetable  physiology. 
It  may  again  be  subdivided  until  the  functional  activity  of  each  of 
the  various  orders  of  animal  and  vegetable  life  is  specially  con- 
sidered. 

Pathology  is  the  study  of  perverted,  abnormal,  or  diseased 
function.  Its  comprehension  must  be  based  upon  a  knowledge  of 
healthy  action.  The  study  of  pathology  may  be  divided  in  the 
same  manner  as  is  physiology.  Wherever  there  is  normal  func- 
tion there  may  be  diseased  or  perverted  action  of  the  tissues  or 
organs,  if  their  activity  is  in  any  way  disturbed.  So  we  may  have 
animal  or  vegetable  pathological  action,  and  we  may  study  this 
aberration  in  any  class  of  animals  or  vegetables,  even  in  any 
separate  organ  or  tissue;  thus  we  speak  of  human  or  animal 
pathology,  and  of  pathological  conditions  of  the  digestive  appa- 
ratus, the  kidneys,  the  pulmonary  tissues,  the  oral  cavity,  the  nails, 
the  teeth,  the  hair,  etc.  This  unrestricted  nature  of  the  study 
must  always  be  kept  in  mind,  and  the  fact  that  in  the  consideration 
of  the  diseases  that  are  incident  to  man  we  are  but  making  an 
examination  of  a  small  portion  of  the  great  field  of  perverted 
activity  should  never  be  lost  to  sight. 

Oral  pathology  is  but  a  branch  of  disturbed  human  function. 
While  we  may  make  special  inquiries  into  its  character,  it  can 
never  be  wholly  segregated  from  its  connections,  but  must 
always  be  considered  in  its  relations  to  impaired  conditions  of 
other  organs,  because  its  initial  lesion,  or  point  of  origin,  may 
be  in  them,  and  a  cure  may  only  be  brought  about  through  a 
return  of  those  connected  organs  to  a  true  state  of  physiological 
activity.  There  is  no  proper  study  of  the  oral  tissues  or  organs 
aside  from  their  functional  association  with  other  tissues  and 
organs. 


BACTERIOLOGY  :       CLASSIFICATION.  3 

A  physiological  state  may  be  changed  to  a  pathological  condi- 
tion by  any  derangement  of  function.  The  modifying  influences 
which  induce  this  may  be  classed  as  follows : 

1.  Perverted  nutrition  (or  malnutrition). 

2.  Unsanitary  surroundings  or  environments. 
J.     External  interference. 

Their  importance  as  disturbing  factors  and  the  gravity  of  the 
functional  disarrangements  induced  by  them  are  in  the  order  given. 

Malnutrition  means  the  improper  nourishment  of  the  tissues 
or  organs.  It  may  primarily  depend  upon  improper  food,  a  lack 
of  food,  or  upon  imperfect  action  of  the  organs  of  digestion  and 
assimilation.  A  degenerate  condition  of  these  organs  is  usually 
brought  about  either  by  impaired  nutrition  or  unhealthy  environ- 
ment, and  it  may  therefore  be  considered  as  a  secondary  cause. 

Unsanitary  or  unhygienic  conditions  are  those  that  interfere 
with  proper  functional  activity,  by  means  of  some  disturbing 
element  or  influence,  such  as 

a.  Contamination  of  the  air  that  is  breathed,  or  the  food  or  drink 
that  is  taken, 

h.  Subjection  of  the  organs  and  tissues  to  improper  extremes  of 
temperature. 

c.  Promotion  of  the  proliferation  and  groivth  of  parasitic  or 
disease-producing  organisms. 

External  interference  has  reference  to  factors  not  primarily 
connected  with  functional  disturbances.  It  includes  wounds  and 
injuries,  the  influence  of  excessive  heat  and  cold,  the  active  agency 
of  corrosive  poisons,  and  such-like  extraneous  causes. 


CHAPTER  XL 

BACTERIOLOGY:     CLASSIFICATION. 

Modern  pathological  science  is  largely  founded  upon  a  knowl- 
edge and  study  of  the  bacteria — a  subdivision  of  the  fungi.     The 

influence  of  these  organisms  upon  the  body  is  so  overwhelming 
that  it  is  impossible  to  comprehend  pathology  without  a  comprehen- 
sion of  their  character  and  action.     So  many  of  the  diseases  most 


4  ORAL    PATHOLOGY   AND    PRACTICE. 

destructive  to  man  are  caused  by  them,  that  modern  medical  science 
is  largely  based  upon  their  study.  Notwithstanding  the  fact  that 
they  can  only.be  seen  by  the  aid  of  the  higher  powers  of  the  micro- 
scope, and  that  even  then  some  of  them  are  absolutely  indefinable 
to  vision,  they  work  the  most  important  changes  in  matter.  Were 
it  not  for  their  influence  the  world  would  become  uninhabitable 
through  the  using  up  of  organic  matter,  which  would  become 
permanently  incorporated  in  unchangeable  compounds  and  the 
pabulum  for  animals  and  vegetables  thus  exhausted. 

The  office  of  the  fungi  seems  chiefly  that  of  destruction.  By 
their  growth  they  decompose  organic  matter  in  which  function 
has  ceased,  and  return  its  elements  to  nature,  to  be  again  built 
up  into  other  structures  by  varying  functional  activities.  ■ 

Different  names  have  been  given  to  these  organisms  by 
different  pathologists,  though  all  have  the  same  general  signifi- 
cation. 

a.  Micro-organism  means  a  small  body. 

b.  Microbe  signifies  a  small  life. 

c.  Bacterium  (plural  Bacteria),  a  small  staff. 

d.  Bacillus  (plural  Bacilli) ,  a  small  rod. 

It  will  be  seen  that  the  first  two  and  the  last  two  names  are 
practically  S3monymous.  While  all  these  terms  may  here  be  used 
interchangeably,  micro-organism  is  perhaps  as  comprehensive  as 
any,  although  it  has  no  strictly  scientific  significance.  All  of  these 
bodies  that  come  within  the  field  of  the  pathologist  are  microscopic ; 
hence  to  speak  of  them  as  micro-organisms  is  more  appropriate 
than  to  call  them  fungi,  the  latter  term  including  many  organisms 
that  are  merely  parasitic  upon  other  vegetable  growths,  while  many 
of  the  fungi  are  not  microscopic  and  have  no  pathological  signifi- 
cance. 

In  general  classification  the  various  divisions  and  subdivisions 
of  matter  are  usually  denominated  as  follows:  Matter  is  divided 
into  Grand  Divisions;  these  into  Kingdoms;  Kingdoms  into  Sub- 
Kingdoms;  Sub-Kingdoms  into  Classes;  Classes  into  Orders;  Orders 
into  Genera,  or  Families;  Genera  into  Species,  and  Species  into 
Varieties. 

The  fungi  have  been  differently  classified  by  various  observers, 
each  having  based  his  arrangement  upon  certain  special  character- 
istics.    That  of  Miller,   in  his   "Micro-organisms  of  the  Human 


BACTliKiOLOGY  :       CLASSIFICATION. 


Mouth,"  is  perhaps  best  adapted  to  the  needs  of  students  of  oral 
pathology,  and  it  is  therefore  accepted  as  the  standard  for  this  work. 
The  following  table  will  give  a  clear  idea  of  it : 

Matter 


Organic 


Inorganic 


Animal 


Vegetable 


Cryptogams  Phanerogams 

(Flowerless  plants,  propagating   (Flowering  plants,  propagating 

by  spores)  by  seeds) 


Thallogens,  Leafy  Cryptogams, 

or  Thallophytes         (Ferns,  Mosses,  etc.) 


Lichens 


Fungi 


Algce 


Screw  forms 

Vibriones 
(undulating) 

Spirillas 

(rigid) 
Spirochetse 
(ilexible) 


Rod  forms  Rou?id  forms 

Bacilli  Micrococci 

(straight  rods)  (small  cocci) 

Clostridium  Macrococci 

(spindles)  (large  cocci) 

Leptothrix  Diplococci 

(threads)  (double  cocci) 

Streptococci 
(chain  cocci) 
Staphylococci 
(group  cocci) 

Organic  matter  is  that  which  is  the  product  of  function,  or 
growth.  Everything  that  has  organs,  or  in  which  function  exists 
or  has  once  existed,  is  organic. 

The  organic  world  is  divided  into  two  great  kingdoms,  the 
Animal  and  the  Vegetable.  Each  individual  member  of  these 
great  divisions  has  its  organs  and  its  tissues;  function  exists  in 
each  as  long  as  there  is  vitality,  or  life.  Death  is  merely  the  cessa- 
tion of  function,  and  the  physicist  makes  no  other  distinction 
between  the  dead  and  the  living  than  the  presence  or  absence  of 
functional  activity. 

The  food  of  these  two  kingdoms  materially  differs.  The 
animal  can  assimilate  nothing  except  organic  matter.  Thus  the 
Graminivora  live  upon  vegetables  alone,  or  matter  that  has  been 
but  once  organized,  and  they  require  a  complicated  digestive  system 
to  extract  the  comparatively  small  amount  of  pabulum  for  their 


6 


ORAL    PATHOLOGY    AND    PRACTICE. 


tissues  which  it  contains.  The  Carnivora  feed  upon  the  animal 
kingdom,  or  matter  that  has  been  twice  organized;  first  into  the 
vegetable  and  then  into  the  animal.  Tlieir  digestive  apparatus 
is  comparatively  simple,  because  of  the  concentrated  nature  of 
their  food.  The  Omnivora,  to  which  division  man  belongs,  can 
subsist  upon  either,  and  their  digestive  organs,  while  more  com- 
plex than  those  of  the  Carnivora,  are  considerably  modified  from 
those  of  the  Graminivora. 


Fig.  I. 


m»*»4 


Different  Forms  of  Bacteria.     (After  Miller.) 
a,  Micrococci,    b,  Diplococci.   c,  Streptococci,    d,  Bacilli,    e,  Vibriones.     /",  Spirillae.    o-,  Clos- 
tridium,   h,  Spirochetae.     z,  Leptothrix. 

Only  organisms  that  belong  to  the  vegetable  kingdom  have 
the  power  of  living  upon  inorganic,  or  unorganized,  matter.  Cer- 
tain of  the  vegetable  fungi  are  unable  even  to  do  this,  but  must 
have  the  food  organized  before  they  can  assimilate  it,  as  must  all 
members  of  the  animal  kingdom. 

Inorganic  matter  is  that  which  exists  as  it  was  first  created. 
This  earth,  when  it  left  the  hands  of  its  Creator,  must  have  consisted 
exclusively  of  inorganic  matter.  When,  in  due  process  of  time, 
the  first  organic  cell  was  created,  and  endowed  with  the  power  to 


BACTERIOLOGY  :       CLASSIFICATION.  7 

adapt  itself  to  changing  environments  and  to  perpetuate  its  species 
— in  other  words,  was  invested  with  function — its  food,  or  pabulum, 
must  have  been  derived  from  the  inorganic  creation.  But  only  the 
vegetable  kingdom  has  the  power  to  assimilate  or  organize  this 
matter,  or  to  subsist  and  grow  upon  that  which  is  as  it  was 
primarily  created.  Hence  the  vegetable  was  first  in  the  order  of 
organic  creation,  and  all  organic  matter,  which  is  the  product 
of  function  and  was  primarily  derived  from  the  inorganic,  must 
have  originally  been  the  result  of  vegetable  action. 

No  animal  can  utilize  for  trophic,  or  digestive,  purposes  any 
inorganic  matter  whatever.  This  is  a  law  of  the  creation.  All 
the  mineral  elements  that  enter  into  the  composition  of  our  teeth, 
bones,  etc.,  must  be  obtained  from  organic  sources.  That  is,  the 
calcium,  phosphorus,  iron,  etc.,'  of  our  tissues  must  have  been 
derived  from  matter  that  had  first  been  built  into  other  life.  Inor- 
ganic matter  may  be  utilized  in  the  system  as  medicine,  but  it  will 
be  extruded  in  the  same  form  in  which  it  entered;  it  cannot  be 
built  up  into  the  tissues.  Even  water,  which  forms  so  large  a  pro- 
portion of  all  organic  bodies  and  which  is  itself  inorganic,  is  not, 
strictly  speaking,  trophic  or  nutritional,  but  is  interstitial.  It  holds 
in  solution  many  salts,  forms  a  part  of  all  crystalline  structures,  and 
is  a  necessary  constituent  of  the  body,  though  not  of  the  elements 
of  the  tissues  themselves.  It  necessarily  follows,  then,  that  in  the 
order  of  the  developmental  history  of  the  world,  the  vegetable 
must  first  have  had  a  being,  to  provide  food  for  the  animal. 

The  vegetable  kingdom  is  divided  into  the  classes  Phanerogam 
and  Cryptogam. 

The  Phanerogams  include  all  those  plants  ivhich  have  blossoms 
and  zvhich  are  propagated  by  seeds.  The  roots  of  some  phanero- 
gams, as  the  potato,  enlarge  into  tubers,  from  which  new  plants 
may  be  grown,  but  their  real  generation  is  from  seeds.  Most  of 
the  plants  with  which  we  are  acquainted  belong  to  this  class.  It  is 
the  seeds  and  the  tubers  of  the  phanerogams  that  form  the  principal 
vegetable  food  of  man. 

The  Cryptogams  never  blossom,  and  their  propagation  is  by 
spores,  or  minute  embryos  of  the  plant  itself.  As  the  potato  may 
be  propagated  from  divisions  of  the  root  or  tuber,  so  do  many  of 
the  cryptogams  grow  from  divisions  of  the  organisms  themselves, 
but  primarily  their  origin  is  from  spore-cases.- 


»  ORAL    PATHOLOGY    AND    PRACTICE. 

The  Leafy  Cryptogams  are  not  microscopic  in  their  character, 
and  they  have  distinct  branches  and  stems.  But,  like  all  of  their 
class,  they  grow  from  spores.  The  leafy  cryptogams  include  the 
ferns,  the  mosses,  and  some  of  the  lichens. 

The  Thallogens,  or  Thallophytes,  belong  to  that  division  of 
the  cryptogams  that  are  unicellnlar  and  simple  in  their  structure. 
They  are  without  leaves,  stems,  or  branches.  They  are  divided 
into  Fungi,  Algae,  and  Lichens. 

Fungi  are  zvithout  chlorophyll  {the  green  coloring  matter  of 
plants),  and  live  only  upon  organic  matter.  They  are  found  as  the 
parasites  of  both  the  animal  and  vegetable  kingdoms. 

AlgcB  contain  chlorophyll,  but  live  upon  inorganic  matter. 
They  are  usually  found  growing  in  the  water. 

Lichens  partake  of  the  character  of  both  the  fungi  and  the 
algcB.  They  may  or  may  not  contain  chlorophyll,  and  they  may 
live  upon  either  organic  or  inorganic  matter,  according  to  their 
species.  They  are  usually  found  attached  to  some  inorganic  matter, 
and  obtain  their  subsistence  from  the  air. 

It  will  be  observed  that  only  the  fungi  can  be  of  interest  to 
the  pathologist,  for  the  algae  do  not  grow  upon  organic  matter, 
and  hence  will  not  be  found  parasitic  in  man,  whose  structure  is 
organic,  while  the  lichens  have  no  pathological  significance. 

The  Fungi  are  divided  according  to  their  shape,  into  round,  rod, 
and  screw  forms. 

The  round,  or  coccus  forms,  are  subdivided  into  the  macro- 
cocci,  or  large  cocci,  the  micrococci,  or  small  cocci,  and  the  diplo- 
cocci,  or  double  cocci,  the  streptococci,  or  chain  cocci,  and  the 
staphylococci,  or  those  which  grozv  in  clusters,  like  a  bunch  of 
grapes. 

The  rod  forms  are  divided  into  the  bacilli,  or  straight  rods; 
the  Clostridium,  or  spindle-shaped,  and  the  leptothrix,  or  thread- 
like forms. 

The  screzv  forms  are  divided  into  the  vibriones,  or  undulating 
screzvs;  the  spirilla,  or  rigid,  and  the  spirochete^  or  flexible  screzvs. 

This  subdivision  as  to  form  is  for  convenience,  and  has  no 
special  pathological  significance.      (See  Fig.  i.) 

Classed  according  to  their  action  the  fungi  are  divided  into 
other  groups,  such  as  Zymogenic  (fermentative).  Pathogenic 
(disease-producing),    Chromogenic    (coloring),    Aerogenic    (gas- 


FERMENTATION.  Q 

forming),    Saprogenic    (putrefactive),    Pyogenic    fpus-producing), 
Saprophytic  (decomposing),  etc. 


CHAPTER  III. 

FERMENTATION. 


A  ferment  is  any  substance  which  has  the  ability  to  bring  about 
the  molecular  oxidation  and  decomposition  or  disintegration  of  the 
carbohydrates  and  proteids,  or  nitrogenous  and  albuminous  com- 
pounds. As  these  are  the  substances  which  are  chiefiy  concerned 
in  the  composition  of  organic  matter,  it  will  be  seen  that  the  process 
is  of  overwhelming  importance,  and  that  without  its  comprehension 
the  student  is  not  prepared  to  consider  any  of  the  constructive  or 
destructive  changes  of  the  body. 

Fermentation  may  be  defined  as  the  change  brought  about  in 
such  organic  medium  by  the  presence  of  a  ferment.  It  is  only  within 
a  recent  period  that  its  true  nature  has  been  comprehended.  It 
was  formerly  ascribed  to  what  was  called  catalytic  action.  It  is 
now  known  to  be  induced  by  a  special  organism  or  substance,  and 
its  phenomena  are  those  produced  by  the  decomposition  of  the 
medium  in  which  the  ferment  is  growing,  or  exhibiting  its  energy. 

There  are  organized  and  unorganized  ferments.  The  action  of 
the  so-called  unorganized  ferments  does  not  essentially  differ  from 
that  of  the  organized.  In  either  the  process  consists  in  a  solution  of 
the  bonds  of  constructive  affinity  and  the  formation  of  new  com- 
pounds— in  active  molecular  derangements  and  rearrangements. 
With  the  organic  ferments  this  is  brought  about  through  the  func- 
tional activities  of  simple  individual  organisms,  while  the  inorganic 
ferments  are  formed  by  and  owe  their  activity  to  a  compound,  com- 
plex structure,  made  up  of  functionally  united  organs,  each  display- 
ing its  activities  for  a  common  purpose. 

The  organized  ferments  are  certain  of  the  micro-organisms 
whose  growth  or  proliferation  is  by  the  assimilation  of  the  elements 
of  the  fermentable  substance.  This  they  have  the  power  to  decom- 
pose, as  a  cabbage  disintegrates  and  resolves  into  its  elements  the 
soil  in  which  it  grows. 

The  unorganized  ferments  are  the  enzymes,  or  those  of  diges- 


lO  ORAL    PATHOLOGY   AND    PRACTICE. 

tion.  The  gastric  and  intestinal  juices,  the  saHva,  etc.,  contain 
ferments  that  decompose  and  change  the  fermentable  foods,  and 
reduce  them  to  a  condition  in  which  they  may  be  assimilated,  or 
built  into  tissue. 

It  is  only  fermentable  organic  matter  that  can  be  thus  digested 
and  assimilated.  Inorganic  matter  is  incapable  of  fermentation, 
and  hence  cannot  serve  as  food  for  any  of  the  tissues  of  the  animal. 

The  classification  of  the  fungi  shows  that  they  are  as  dis- 
tinctly vegetable  as  is  a  potato  or  a  geranium.  The  fact  that  they 
belong  to  a  different  order,  and  are  cryptogams  instead  of  phanero- 
gams, does  not  change  this.  They  require  for  their  development 
the  same  essential  conditions  and  elements.  They  must  have  the 
proper  soil,  or  menstruum,  in  which  to  proliferate,  or  grow,  as  must 
the  flowers  of  the  garden  or  field.  They  require  a  proper  amount 
of  moisture,  as  does  corn  or  wheat.  They  demand  a  fitting  tem- 
perature, and  are  destroyed,  or  cease  to  vegetate,  when  that  is 
either  too  high  or  too  low,  as  are  grass,  trees,  and  shrubs. 

The  media,  or  soils  or  materials  in  which  the  different  species 
of  micro-organisms  grow,  are  as  various  as  are  the  fungi  themselves. 
Some  require  a  sugar  solution,  made  from  the  fermentable  sugars 
formed  by  the  change  of  starch  into  the  so-called  grape  sugar. 
Some  demand  an  infusion  prepared  by  steeping  vegetables  belong- 
ing to  the  phanerogams.  Some  grow  only  in  gelatins.  Others 
exist  only  in  the  tissues,  or  extracts  of  the  tissues,  of  animals. 

The  temperature  best  adapted  to  their  growth  varies  with  the 
organism.  With  those  that  live  in  the  tissues,  that  which  is  normal 
to  the  body  is  also  normal  to  them. 

The  growth  of  the  organisms,  although  primarily  from 
spores,  goes  on  in  various  ways. 

Segmentation  is  the  spontaneous  division  of  a  micro-organism 
into  segments,  or  sections.  Each  is  complete  in  itself,  and  each 
in  turn  subdivides  into  others. 

Gemmation  is  the  process  of  proliferation  by  budding.  This  is 
the  growth  of  one  organism  out  of  another,  and  its  final  separa- 
tion from  the  parent. 

Fission  is  the  division  of  an  organism  into  two  or  more  parts 
by  a  constriction  of  its  body.  This  contraction  gradually  deepens 
until  the  separation  is  complete. 

Spore  formation  occurs  when  in  certain  stages  of  its  life-history 


FERMENTATION. 


II 


an  organism  undergoes  special  changes.  In  these  the  interior  breaks 
up  into  exceedingly  minute  embryos,  which  are  Hberated  and 
dispersed  by  the  bursting  of  the  external  envelope.  Many  of  the 
organisms  which  at  certain  stages  of  their  existence  proliferate  by 
means  of  segmentation  or  gemmation,  after  a  definite  time  break 
up    into    spores.      Something    analogous    to    this    exists    among 


»a833 


Fig.  2. 


Q  9  i&  09   09 


<^8  98  ^ 


a. 


c. 


Methods  of  Proliferation  of  the  Bacteria. 
a,  b,  c,  Fission  or  segmentation,    d,  d> ,  Sporulation.    ^,  e^.  Gemmation  or  budding  of 


phanerogams,  the  potato,  for  instance,  being  propagated  by  sub- 
division of  its  tubers,  but  in  due  process  of  time  blossoming  and 
forming  seed-cases.      (See  Fig.  2.) 

The  growth  of  micro-organisms  proceeds  by  the  decomposition 
of  the  medium  in  which  they  exist.  They  assimilate  such  of  its 
elements  as  are  essential  to  their  own  composition,   leaving  the 


12 


ORAL    PATHOLOGY    AND    PRACTICE. 


remainder  to  form  various  waste  products,  and  give  rise  to  new 
combinations  of  such  of  the  elements  of  the  medium  as  are  rejected. 
Under  favorable  circumstances,  micro-organisms  multiply  with 
almost  inconceivable  rapidity.  Cohn  estimates  the  life-history  of 
a  single  bacterium  at  an  hour,  at  the  end  of  which  time  it  will 
divide  into  two  or  more.  He  computes  that  from  a  single  indi- 
vidual, if  all  the  circumstances  were  favorable,  within  five  days  the 
product  might  fill  all  the  seas  of  the  globe. 

Fic.    V 


The  Yeast  Fungus. 

The  proliferation  of  the  Torula,  or  Yeast-plant,  may  be  taken 
as  a  type  of  the  whole  process.  This  fungus  consists  of  single  cells, 
produced  by  division  of  the  parent  cell.  (See  Fig.  3.)  It  grows 
in  sugar  solutions  with  the  greatest  rapidity,  but  a  short  time  being 
required  for  the  permeation  of  a  large  mass  by  the  product  of  a 
single  cell.  The  process  of  making  bread  illustrates  this.  The 
housewife  mixes  flour,  which  consists  of  starch,  that  is  easily  con- 
verted into  a  fermentable  sugar,  with  a  sufficiency  of  water;  she 
then  places  the  product  in  a  warm  place,  after  having  introduced  a 
few  cells  of  the  yeast-plant.  Here  are  all  the  elements  needed  for 
development — a  suitable  medium,  sufficient  moisture,  and  the 
proper  temperature. 


FERMENTATION.  1 3 

The  yeast-plant  commences  its  growth  and  permeates  all 
parts  of  the  mixture.  It  decomposes  the  sugar,  separating  the 
oxygen,  carbon,  and  hydrogen.  It  builds  into  itself  that  which 
is  necessary  and  rejects  the  other  atoms,  which  immediately  enter 
into  new  combinations,  forming  as  by-products,  alcohol  and  carbon 
dioxide.  Wherever  a  cell  of  the  yeast-plant  is  formed,  there  is  left 
as  by-products  a  bit  of  alcoliol  and  a  minute  globule  of  carbon 
dioxide  gas.  The  latter  distends  the  dough,  or  causes  it  to  "rise." 
When  this  is  completed  it  is  placed  in  the  heated  oven,  with  the 
result  that  the  yeast-plant  is  killed,  and  the  dough  is  fixed,  or  cooked, 
and  becomes  bread.     Beer-making  is  an  analogous  fermentation. 

The  alcoholic  fermentation  is  that  zvhich  results  in  the  formation 
of  alcohol  as  one  of  the  by-products.  The  fermentation  of  grape 
juice,  and  the  formation  of  alcohol  from  the  starch  of  various 
grains,  belong  to  this  class.  The  growth  of  the  ferment  produces 
alcohol,  which  is  held  in  solution  in  the  water,  and  is  then  distilled 
off  by  its  evaporation  at  a  comparatively  low  temperature. 

The  acetous,  or  acid,  fermentation  is  the  groiuth  of  yet  another 
organic  ferment,  that  leaves  as  a  by-product  an  acid.  Of  this  char- 
acter is  the  organism  Mycoderma  aceti,  or  the  so-called  "mother" 
of  vinegar.  It  decomposes  a  sugar  solution,  and  produces  acetic 
acid  as  a  by-product.  In  like  manner,  through  the  action  of  dif- 
ferent organisms,  are  produced  all  of  the  very  many  true  organic 
acids.  Others  of  the  fungi  produce  gelatin,  and  yet  others  various 
gases. 

The  putrefactive  organisms  decompose  nitrogenous  matter  by 
their  growth,  with  the  evolution  of  offensive  gases  as  their  hy- 
products.  All  the  fungi  grow  at  the  expense  of  the  medium  in 
which  they  exist,  and  through  its  decomposition,  or  molecular 
change.  Their  by-products  vary  with  the  organisms  themselves, 
and,  as  in  the  case  of  the  ptomains  and  toxins,  are  sometimes  of 
such  a  poisonous  nature  as  to  induce  diseased  or  pathological 
conditions. 

Some  of  the  fungi  grow  only  in  the  presence  of  air  or  oxygen, 
and  hence  are  called  "aerobic,"  while  others  flourish  in  tissues  or 
cavities  to  which  air  has  no  access,  and  are  called  "anaerobic." 

They  are  also  said  to  be  "obligate,"  those  whose  demand  for 
the  presence  or  absence  of  oxygen  is  imperative  and  peremptory, 
and  "facultative,"  those  which  flourish  best  in  one  condition  or  the 


14  ORAL    PATHOLOGY   AND    PRACTICE. 

Other,  though  able  to  proHferate  either  as  aerobic  or  anaerobic 
organisms. 

The  bacteria  generally  are  self-limiting.  Their  own  by- 
products are  fatal  to  them,  and  when  the  medium  in  which  they 
are  growing  becomes  sufficiently  contaminated  the  organisms  will 
perish.  Thus,  when  an  acid-producing  organism  has  made  its 
menstruum  sufficiently  acid,  it  will  die  unless  the  acid  is  neutralized 
by  an  alkali,  in  which  case  it  goes  on  proliferating,  provided  the 
pabulum,  or  nutritive  supply,  is  not  exhausted.  All  the  ferment- 
able material  in  a  solution  may  be  used  up  and  decomposed,  so  that 
there  will  no  longer  be  food  for  the  organism,  in  which  case  it  will 
die  out. 

One  organism  may  destroy  and  supersede  another  by  its  superior 
activity  and  power  of  decomposition,  or  through  its  production  of  a 
chemical  compound  that  is  fatal  to  the  first.  The  brewer  must  use 
the  most  scrupulous  care  to  prevent  the  intrusion  of  a  strange 
organism  into  his  infusion,  or  the  result  may  be  an  acid  instead  of 
an  alcohol,  with  the  consequent  souring  of  his  beer.  The  housewife 
"scalds"  the  pans  -and  other  utensils  in  which  milk  is  kept,  and 
submits  them  to  strong  sunlight  that  all  infective  or  acid-producing 
organisms  may  be  destroyed. 


CHAPTER  IV. 

BACTERIOLOGICAL  PATHOLOGY. 

From  the  standpoint  of  the  pathologist,  the  micro-organisms 
may  be  divided  into  several  classes,  according  to  their  action  upon 
the  animal  economy. 

Pathogenic  microbes  are  those  whose  proliferation  or  whose  by- 
products  cause  specific  pathological  changes;  they  are  disease-pro- 
ducing. 

Saprogenic  organisms  are  those  which  cause  putrefaction,  or 
the  decomposition  of  nitrogenous  matter,  with  the  solution  of 
ammonia  and  hydrogen  sulphide  gases. 

Pyogenic  micro-organisms  induce  suppuration,  or  the  forma- 
tion in  living  tissues  of  pus,  zvhich  is  the  Huid  produced  in  the 
process  of  suppuration. 


BACTERIOLOGICAL    PATHOLOGY.  I5 

Saprophytic  bacteria  are  those  zvhich  live  only  on  dead  matter; 
they  induce  decomposition  and  disruption  of  the  elements  of  the 
functionless  organic  matter  in  which  they  proliferate. 

For  the  study  of  any  of  these  micro-organisms  it  is  necessary 
to  make  pure  cultures,  obtained  by  implanting  them,  as  they  are 
mixed  with  others,  in  the  best  culture  media,  and  separating  out 
and  replanting  selected  colonies  until  everything  has  been  elimi- 
nated save  that  which  it  is  desired  shall  be  investigated.  They 
cannot  be  identified  by  a  microscopic  inspection  of  the  organisms 
themselves, — they  are  too  minute  for  this  purpose.  But  by  observa- 
tion of  the  phenomena  of  their  growth,  and  by  tests  of  their 
products,  as  well  as  by  staining  them  with  certain  aniline  dyes  which 
do  not  afifect  their  surroundings,  they  may  readily  be  differentiated, 
or  distinguished  from  other  organisms. 

To  produce  a  pure  culture  of  any  organism,  an  incubator, 
or  growing-chamber,  is  required,  in  which  the  exact  amount  of 
moisture  and  the  proper  temperature  may  be  maintained  prac- 
tically unchanged  for  an  indefinite  period. 

Micro-organisms  penetrate  everywhere  that  air  can  go.  So 
innumerable  are  the  different  species,  and  so  minute  their  size, 
the  spores  of  many  of  them  being  invisible  even  beneath  the 
highest  powers  of  the  microscope,  that  everything  conceivable 
becomes  infected  with  the  seeds  of  disease  and  decay.  A  single 
species  has  in  the  past  caused  greater  alarm  and  devastation  than 
all  the  armies  of  the  most  pitiless  conqueror  who  ever  ravaged  the 
earth.  The  bacillus  that  produces  cholera  has  decimated  nations. 
The  various  plague  bacteria  have  invaded  great  cities  and  de- 
stroyed every  second  person.  They  have  defeated  and  dispersed 
invading  armies,  and  have  stayed  the  march  of  destroying  hosts. 
The  bubonic  plague,  which  is  the  result  of  the  growth  of  a  patho- 
genic organism,  has,  in  the  past,  swept  away  one-third  of  the 
population  of  Europe  in  a  single  invasion. 

A  few  of  the  most  fatal  of  the  maladies  which  are  the  direct 
result  of  the  growth  of  some  special  organism,  and  which  are 
therefore  contagious  in  their  character — the  so-called  zymotic 
diseases,  of  either  epidemic  or  endemic  origin — are  the  following: 
Cholera,  Diphtheria,  Relapsing  Fevers,  Leprosy,  Typhoid  Fever, 
Syphilis,  Smallpox,  Septicemia,  Osteomyelitis,  Tuberculosis, 
Lupus,    Tetanus,    Glanders,    Actinomycosis,    Malignant    Pustule, 


l6  ORAL    PATHOLOGY    AND    PRACTICE. 

Gonorrhea,  Leucorrhea,  Scarlet  Fever,  Mumps,  Meningitis,  Ery- 
sipelas, Carbuncle,  Pneumonia,  Rabies,  Anthrax. 

Late  investigations  have  shown  that  the  one  malady  that 
in  this  country  is  responsible  for  more  deaths  than  any  other,  tuber- 
culosis or  consumption,  is  as  communicable  as  smallpox,  and  can 
only  be  acquired  through  infection.  Its  period  of  incubation,  or 
development,  is  longer  than  that  of  most  infectious  diseases,  but  it 
can  be  as  certainly  stamped  out  by  isolation,  disinfection,  and  the 
use  of  antiseptics  as  can  cholera,  that  former  scourge,  which  in  the 
light  of  our  modern  knowledge  of  bacteriology  is  now  so  readil)^ 
controlled. 

Were  there  no  means  of  resisting  the  invasion  and  growth  of 
the  special  organisms  which  induce  these  diseases,  and  of  impeding 
their  multiplication,  they  would  inevitably  depopulate  the  earth. 
It  has  already  been  asserted  that  they  are  self-limiting  in  their 
proliferation,  through  their  inability  to  exist  in  the  presence  of 
their  own  waste  products.  They  may  also  exhaust  the  soil  or 
medium  in  which  they  grow,  and  thus  circumscribe  their  own 
multiplication. 

The  most  material  factor  in  the  prevention  of  the  increase  of 
the  zymotic  diseases  is  the  resistive  power  of  healthy  animal  func- 
tion. Under  ordinary  circumstances,  the  human  body  successfully 
reacts  against  infection,  and  prevents  undue  proliferation  of  patho- 
genic organisms.  If,  however,  the  bodil}^  tone  is  depressed 
through  malnutrition,  by  unsanitary  conditions,  by  fatigue  or 
exhaustion,  or  because  of  functional  disturbances,  the  resistive  force 
of  the  body  is  so  much  weakened,  and  the  conditions  favorable  to 
the  growth  of  the  disease  fungi  so  augmented,  that  they  multiply 
to  an  extent  sufficient  to  bring  about  that  pathological  condition 
which  accompanies  their  invasion. 

Conclusive  experiments  upon  animals  have  demonstrated  this. 
Rabbits  are  immune  to  tubercular  infection  under  ordinary  condi- 
tions. Twelve  of  these  animals  were  selected;  six  of  them  were 
kept  for  some  time  in  a  dank  and  noisome  cellar,  and  insufficiently 
fed  upon  unwholesome  food.  The  other  six  were  kept  in  complete 
sanitary  condition,  in  light  and  airy  rooms,  and  were  fed  with 
the  best  food.  At  the  end  of  a  definite  period  each  was  inoculated 
with  Bacillus  tuberculosis.  All  of  the  first  six  took  the  infection 
and  died  of  it;  the  six  whose  bodily  tone  had  been  preserved  by 


BACTERIOLOGICAL    PATHOLOGY. 


17 


pure  air  and  good  food  retained  their  immunity,  and  successfully 
resisted  infection. 

Twelve  rats  were  selected,  and  six  of  them  placed  in  a 
revolving  wheel  that  forced  them  to  run  at  a  rapid  gait  for  a 
considerable  time.  The  other  six  were  allowed  to  remain  in  a 
quiet  place,  where  they  would  not  be  annoyed  or  irritated.  When 
the  first  six  had  been  forced  to  run  until  they  were  exhausted,  all 
the  twelve  were  inoculated  with  an  organism  from  which  under 
ordinary  circumstances  rats  have  exemption  from  infection. 
Those  whose  resisting  powers  had  been  reduced  by  extreme 
fatigue  and  exhaustion  took  the  contagion  and  died,  while  the 
others  were  unafifected. 

Fig.  4. 


J. 


Leucocytes. 
b,  c.    Ameboid    forms    assumed    by  them,  with    pseudopodia.     a^,   U^,    Ingestion    and 
digestion  of  bacteria. 


The  resistive  power  of  the  human  body,  according  to  Metch- 
nikoff,  is  largely,  though  not  exclusively,  inherent  in  the  ameboid 
white  blood  corpuscles,  which  in  a  state  of  health  envelop  and 
digest  the  bacteria.  (See  Fig.  4.)  When  these  are  not  fully 
formed  in  the  system,  when  they  are  diminished  in  number  or 
reduced  in  functional  activity,  the  infective  organisms  may  obtain 
such  preponderance  as  to  overcome  all  resistance,  and  run  their 
course  until  they  produce  death,  or  become  self-limiting  through 
the  formation  of  their  own  by-products  and  the  exhaustion  of  the 
media  in  which  they  grow. 

The  bacteria  are  greatly  multiplied  in  the  presence  of  any 
putrefactive  or  decomposing  material.  Hence  all  decaying  matter 
should  be  destroyed  as  far  as  possible,  by  some  quicker  and  more 

3 


16  ORAL    PATHOLOGY    AND    PRACTICE. 

hygienic  process  than  its  decomposition  by  the  fungi.  Sanitary 
conditions  imply  the  removal  of  all  infective  matter,  and  modern 
hygiene  is  mainly  the  study  of  how  best  to  accomplish  this.  Such 
progress  has  been  made  within  the  past  generation,  that  the 
average  period  of  human  life  has  been  lengthened  several  years, 
almost  entirely  through  the  ability  of  sanitarians  to  control  the 
multiplication  of  disease  spores. 


CHAPTER  V. 

SEPTIC  AND  ASEPTIC  CONDITIONS. 

The  state  of  infection  by  disease-producing,  or  putrefactive, 
organisms  is  called  a  septic  condition,  and  whatever  tends  to 
combat  this  is  said  to  be  antiseptic  in  its  character.  A  state  of 
freedom  from  all  degenerative  organisms  is  an  aseptic  or  sterile 
condition,  and  it  may  be  brought  about  by  various  agencies,  either 
of  a  physical  or  medicinal  nature.  As  moisture  is  one  of  the 
elements  necessary  to  the  growth  of  the  fungi,  it  may  be  readily 
comprehended  that  its  entire  removal  will  stop  all  development. 
Hence  dry  climates  or  desiccated  conditions  are  unfavorable  tO'  the 
growth  of  bacteria.  On  the  elevated  plains  of  South  America  beef 
is  indefinitely  preserved  by  drying  it  in  the  sun.  In  other  countries 
the  same  thing  is  accomplished  by  artificial  evaporation. 

The  proper  degree  of  temperature  is  essential  to  growth,  and  the 
raising  or  lowering  of  this  beyond  a  certain  point  will  limit  or 
prohibit  it,  a  definite  amount  of  heat  being  sufficient  to  destroy  all 
organisms  and  render  sterile  any  substance  whatever.  Upon  the 
tops  of  high  mountains,  above  the  line  of  perpetual  snow,  the 
bacteria  are  almost  non-existent.  The  cold  weather  of  our  freezing 
winters  stops  the  spread  of  the  most  virulent  zymotic  diseases,  and 
fermentation  and  putrefaction  cease,  except  in  the  presence  of 
artificial  heat. 

There  are  also  certain  drugs  that  have  the  ability  to  destroy 
or  prevent  the  growth  of  septic  organisms. 

Those  that  are  fatal  to  the  bacteria  and  their  spores  are  called 
Germicides. 


SEPTIC   AND   ASEPTIC    CONDITIONS.  IQ 

Those  that  limit  and  prevent  their  growth  are  classed  as  Anti- 
septics. 

Those  that  decompose  or  remove  the  by-products  of  infection 
are  called  Disinfectants. 

Those  that  either  mask  or  remove  the  offensive  smells  of  putre- 
faction are  denominated  Deodorants. 

The  most  effective  of  all  the  agents  used  for  sterilization  is 
heat.  The  temperature  of  boiling  water  (212°  F.,  100°  C.)  is  fatal 
to  many  of  the  septic  organisms.  But  as  the  spores  of  some  of 
them  may  successfully  withstand  this,  it  cannot  in  all  cases  be  de- 
pended upon.  Continuous  boiling  for  some  time  will  be  sufficient 
to  destroy  most  of  the  organisms  contained  in  water.  Yet,  if  it  is 
to  be  positively  sterilized,  it  must  be  distilled.  If  an  instrument  is 
passed  through  the  flame  of  burning  gas,  or  of  an  alcohol  lamp,  it 
will  be  made  positively  sterile,  but  this  is  in  some  cases  impracti- 
cable, because  it  will  destroy  the  usefulness  of  steel  tools  by  draw- 
ing the  temper.  The  tissues  of  the  body,  and  of  most  organic  mat- 
ter, cannot  be  raised  to  a  temperature  sufficient  to  insure  an  aseptic 
condition,  and  hence  we  are  compelled  to  depend  upon  germicides, 
antiseptics,  and  disinfectants  in  the  treatment  of  septic  conditions. 

Most  germicides  are  to  a  greater  or  less  extent  antiseptic  in 
their  nature.  That  is,  agents  that  have  the  power  to  destroy 
germs  will  also  prevent  their  growth.  Many  of  the  antiseptics 
are  at  the  same  time  germicides  and  disinfectants,  and  vice  versa. 
In  the  selection  of  drugs  for  medicinal  purposes  it  is  necessary 
to  consider  something  more  than  their  germicidal  or  antiseptic 
qualities.  One  that  is  a  virulent  poison  cannot  with  safety  be 
administered  internally,  nor  can  one  that  is  a  cauterant  be  used 
on  delicate  tissues.  It  is  therefore  necessary  to  comprehend  the 
therapeutics  of  antisepsis,  and  to  select  the  remedy  to  be  used  in 
full  view  of  these  facts. 

Pure  germicides  are  not  always  demanded  in  actual  practice. 
If  a  proper  disinfectant  is  first  employed  to  remove  the  products  of 
sepsis,  and  to  cleanse  the  infected  tissues,  it  will  commonly  serve 
every  purpose.  Most  of  the  disinfectants  that  are  in  general 
remedial  use  not  only  remove  or  decompose  the  products  of  infec- 
tion, but  are  fatal  to  the  germs  themselves,  and  to  the  extent  of  their 
antiseptic  influence  inhibit  or  prevent  their  growth.  Hence  it  is 
not  ordinarily  necessary  to  follow  the  use  of  a  disinfectant  like 
peroxide  of  hydrogen  by  a  strictly  germicidal  or  antiseptic  agent. 


20  ORAL    PATHOLOGY   AND    PRACTICE. 

The  necessities  and  conditions  of  oral  practice  are  such  as  to 
exclude  many  disinfectants,  unless  they  are  securely  sealed  up 
within  the  cavity  of  a  tooth.  If  they  are  of  a  caustic  nature,  they 
will  induce  complicating-  lesions.  If  they  are  specially  toxic,  or 
poisonous,  they  may  bring  about  serious  derangements.  There- 
fore, in  their  selection,  the  judicious  practitioner  will  exercise  great 
care,  and  choose  those  which,  with  the  highest  degree  of  effective- 
ness in  their  special  action,  at  the  same  time  are  not  injurious  to 

Fig.  5. 


The  Comma  Bacillus  of  Cholera. 

Other  'tissues.  In  this  respect  carbolic,  or  phenic,  acid,  a  drug  that 
has  been  in  most  common  use  in  oral  practice,  is  exceedingly 
objectionable. 

The  following  list  of  remedies,  formulated  by  Prof.  W.  D. 
Miller  from  personal  experimentation,  and  first  published  in  the 
"Independent  Practitioner"  for  June,  1884,  indicates  their  relative 
antiseptic  power,  but  is  not  by  any  means  intended  as  a  guide  for 
choice  in  administration.  It  gives  the  dilutions  in  which  each 
will,  under  favorable  circumstances,  limit  the  growth  of  micro- 
organisms: 


SEPTIC   AND   ASEPTIC    CONDITIONS.  21 


Mercuric  Iodide, 

I  part  in  200,000 

Mercuric  Bichloride, 

ii 

100,000 

Silver  Nitrate, 

<< 

50,000 

Hydrogen  Peroxide, 

<< 

8,000 

Tinct.  Iodine, 

« 

6,000 

Iodoform, 

(t 

5,000 

Naphthalin, 

<( 

4,000 

Salicylic  Acid, 

te 

2,000 

Oil  Mustard, 

ti 

2,000 

•Benzoic  Acid, 

ii 

1,500 

Potassium  Permanganate, 

a 

1,000 

Oil  Eucalyptus, 

a 

600 

Carbolic  Acid, 

<< 

500 

Hydrochloric  Acid, 

« 

500 

Borax, 

« 

350 

Arsenic, 

(< 

250 

Zinc  Chloride, 

tt 

250 

Lactic  Acid, 

n 

125 

Sodium  Carbonate, 

(( 

100 

Listerine, 

(( 

20 

Alcohol, 

« 

10 

Potassium  Chlorate, 

« 

8 

The  disinfectants  act  chiefly  through  their  ability  to  decompose 
offensive  products.  This  is  usually  brought  about  by  the  presence 
of  free  oxygen,  or  that  which  is  held  in  loose  combination.  Chlorin- 
ated solutions  are  effective  through  their  ability  to  decompose 
water,  thus  setting  free  one  or  more  volumes  of  oxygen,  which  is 
really  the  agent  of  decomposition.  Hydrogen  peroxide  is  very 
widely  employed  in  oral  practice,  because  it  so  readily  parts  with 
its  extra  volume  of  oxygen.  Pyrozone  is  a  more  permanent  and 
abiding  preparation  of  nearly  the  same  character.  Electrozone, 
which  is  a  decomposed  solution  of  ordinary  sea-water,  is  very 
effective,  and  has  the  advantage  of  being  entirely  innoxious.  It 
may  be  swallowed,  or  used  on  the  most  delicate  tissues,  without  ill 
effects.  It  is  produced  by  an  electrolytic  current,  which  decomposes 
the  chlorides  and  bromides  of  the  salts,  changing  them  into  hypo- 
chlorites and  bromites,  and  these  are  most  effective  disinfectants. 

Deodorants  are  not  necessarily  chemical  agents.  They  may 
merely  be  able  to  absorb   noxious  matter.     An  excellent  one   is 


22  ORAL    PATHOLOGY   AND   PRACTICE. 

pulverized  charcoal,  which  has  the  power  to  absorb  a  number 
of  times  its  own  volume  of  deleterious  gases.  It  thus  acts  also 
as  a  disinfectant.  The  deodorants  most  commonly  employed  by 
oral  practitioners  are  drugs  of  such  penetrating,  though  pleasant, 
perfume  that  they  cover  and  mask  the  odors  of  putrefaction,  though 
without  in  any  way  neutralizing  or  decomposing  them.  It  is  need- 
less to  say  they  have  no  special  therapeutic  value. 

Detergents  are  cleansing  remedies  which  are  sometimes  in  de- 
mand. They  have  no  particular  medicinal  virtue,  but  remove 
certain  superficial  deposits  from  tissue  surfaces,  or  from  wounds, 
ulcers,  etc.  Pure  water  is  excellent  for  this  purpose,  or  a  solution 
of  borax,  of  common  salt,  or  of  soap  may  be  used. 

Suppuration  is  primarily  the  breaking  down  of  the  product 
of  inflammation,  and  its  infection  by  a  special  microbe.  Whether 
the  breaking  down  is  due  to  the  organism,  or  vice  versa,  was  long 
a  disputed  question.  More  recent  investigations  have  established 
the  fact  that  it  is  infection  that  brings  about  the  devitalization  of 
the  blood  corpuscles  and  the  production  of  pus,  and  yet  it  has  been 
demonstrated  that  it  is  possible  for  pus  corpuscles  to  be  produced 
without  the  presence  of  bacteria.  Such  a  condition  must,  however, 
be  unusual,  and  it  cannot  present  all  the  characteristics  of  the  sup- 
puration induced  by  pyogenic  organisms. 

Ordinary  pus  is  composed  of  certain  nucleolar  corpuscles  that 
are  indistinguishable  from  the  white  blood  cells,  and  which  are 
supposed  to  be  these  dead  leucocytes,  the  extravasated  serum  of  the 
blood,  and  such  broken-down  tissue  cells  as  may  exist  in  a  certain 
state  of  degeneration.  This  material  is  found  infected  with  certain 
pyogenic  fungi.  The  formation  and  presence  of  pus  is  accompanied 
with  the  pyogenic  fever,  and  its  presence  in  the  tissues  may  also, 
imder  favorable  circumstances,  be  determined  by  fluctuation  beneath 
the  fingers.  When  it  is  formed  within  the  tissues  it  makes  its  way 
to  the  surface  by  the  readiest  route,  that  of  least  resistance,  through 
the  process  of  rotting  or  breaking  down  of  the  obstructing  tissue, 
and  thus  forms  an  abscess.  The  process  of  suppuration  is  essen- 
tially one  of  extrusion,  or  expulsion  of  effete  or  dead  matter.  That 
inoculation,  or  infection  of  healthy  tissue  with  the  suppurative 
bacteria,  will  induce  the  formation  of  pus  and  the  production  of  an 
abscess  is  thoroughly  established.  Hence,  in  all  curative  processes 
it  is  essential  to  use  the  utmost  care  to  avoid  infection,  and  all  the 


SEPTIC    AND   ASEPTIC    CONDITIONS.  2$ 

modern  methods  of  antiseptic  surgery  are  built  upon  the  abiUty 
to  control  the  growth  of  septic  organisms. 

All  of  the  pathogenic  and  pyogenic  bacteria  are  very  easily 
communicated,  either  by  direct  contact  and  contamination,  or 
through  their  spores,  which  may  be  floating  in  infected  air. 
Modern  surgery  is  superior  to  that  of  a  few  years  since  in  the  re- 
sults obtained;  surgeons  have  learned  how  to  avoid  and  guard 
against  septic  infection.  It  is  now  known,  for  instance,  that  if 
erysipelas  once  makes  its  appearance  in  the  surgical  ward  of  a 

Fig.  6. 


Bacillus  of  Diphtheria. 


hospital,  mere  exposure  to  the  contaminated  air  will  be  likely  ta 
induce  erysipelatous  inflammation  in  any  patient,  but  especially 
those  in  an  atonic  or  debilitated  condition.  The  bacillus  of  diph- 
theria has  been  known  to  be  carried  by  a  garment  that  had  been 
repeatedly  washed  after  infection.     (See  Fig.  6.) 

Infection  may  be  carried  upon  the  hands,  in  the  clothing,  or  by 
instruments  and  implements.  The  surgeon  who  would  now  attempt 
even  minor  operations  without  the  most  strict  aseptic  precautions 
would  be  deemed  unfit  to  practice  his  profession.  His  hands  must 
be  most  thoroughly  washed,  all  impurities  removed  from  beneath 
the  nails,  and  they  must  finally  be  carefully  drenched  with  a  steriliz- 


24  ORAL    PATHOLOGY   AND    PRACTICE. 

ing  solution,  that  no  contaminating  fungi  may  be  carried  to  a 
wound.  Every  instrument  used  must  be  kept  in  a  sterilizing  solu- 
tion, and  sponges  and  lints  must  be  heedfully  rendered  non-infec- 
tious. The  ordinary  clothing  must  be  covered  with  clean  linen 
garments,  that  are  less  liable  to  carry  infection  than  woolen,  and 
every  article  used  must  be  scrupulously  clean. 

The  dentist  should  always  wear  a  clean  linen  coat  at  the  chair. 
Any  woolen  overgarment  must  soon  become  thoroughly  impreg- 
nated with  disease  germs,  and  thus  he  may  carry  contagion  to  suc- 
cessive patients.  He  himself  and  the  most  healthy  and  vigorous 
of  them  may  be  able  to  resist  infection,  but  those  who  are  weak  and 
anemic  and  who  do  not  possess  the  same  withstanding  ability  may 
be  seriously  affected.  Omission  of  these  proper  precautions  will 
also  be  likely  to  result  in  infection  and  suppuration  of  the  wounds 
which  may  be  accidentally  or  are  necessarily  made,  and  even  gan- 
grene may  be  the  consequence. 

Every  operative  dentist,  or  oral  surgeon,  needs  to  exercise  espe- 
cial care  in  this  direction.  There  is  no  mouth  that  does  not  contain 
some  species  of  bacteria.  Indeed,  the  presence  of  some  of  them 
seems  essential  to  perfect  health,  because  they  exercise  a  distinct 
diastatic  function,  and  thus  in  normal  conditions  may  assist  in  the 
process  of  digestion.  The  human  mouth  presents  all  the  conditions 
favorable  to  the  growth  of  the  bacteria,  because  the  debris  from 
different  kinds  of  food,  especially  of  starches,  is  always  present. 
The  diastatic  action  of  the  saliva  converts  these  into  fermentable 
sugars,  and  thus  presents  the  best  medium  for  the  proliferation  of 
very  many  of  the  bacteria.  Moisture  exists  in  sufficient  quantity, 
and  the  temperature  is  exactly  that  best  suited  to  their  development, 
and  it  is  maintained  at  a  point  as  constant  as  could  be  secured  in  the 
most  perfect  incubator.  Indeed,  the  human  mouth  is  a  more  perfect 
growing-chamber  for  the  breeding  of  germs  than  any  that  the 
ingenuity  of  man  could  possibly  devise.  Not  only  is  the  tempera- 
ture uniform  and  the  media  and  moisture  at  the  best,  but  fresh 
pabulum  is  constantly  added,  while  the  by-products  are  promptly 
removed  and  neutralized,  so  that  there  is  no  limitation  of  growth 
through  their  formation. 

The  importance  of  every  antiseptic  precaution  on  the  part  of 
the  practicing  dentist  cannot  be  overestimated.  He  frequently 
meets  with  pus  in  the  oral  cavity,  with  gangrenous  pulps  in  teeth, 


inflammation:     its  general  characteristics.  25 

and  his  instruments  are  almost  constantly  infected  with  septic 
organisms.  These  may  be  deeply  buried  beneath  the  debris 
between  the  leaves  of  burs  and  the  serrations  of  files,  so  that 
mere  rinsing  in  a  sterilizing  fluid  will  not  sterilize,  and  infec- 
tion of  perhaps  the  most  loathsome  character  may  be  carried  to 
the  mouth  of  the  next  patient,  unless  scrupulous  care  is  used. 
It  is  something  more  than  a  professional  blunder  when  an  operator 
will  work  in  the  presence  of  pus,  or  any  infection,  without  subse- 
quently cleaning  and  sterilizing  in  the  most  thorough  manner 
every  instrument  employed,  by  means  of  a  specially  devised 
apparatus,  and  the  use  of  disinfecting  agents,  such  as  bichloride 
of  mercury,  carbolic  acid,  potassium  permanganate,  formalin,  and 
other  solutions. 


CHAPTER  VI. 

INFLAMMATION:  ITS  GENERAL  CHARACTERISTICS. 

A  careful  study  of  the  etiology,  symptomatology,  and  pathol- 
ogy of  the  inflammatory  process  is  of  the  first  importance  to  the 
student  in  dental  medicine,  because  with  bacteriology  it  forms  the 
basis  of  most  degenerative  changes.  Nor  is  it  only  concerned  in 
retrogression.  If  hyperemia  is  accepted  as  one  of  the  early  stages 
of  the  inflammatory  process,  it  is  an  important  factor  in  many 
physiological  and  progressive  metamorphoses  as  well.  Wounds 
are  healed  and  lesions  repaired  through  its  agency  in  some  of  its 
many  phases;  it  is  thus  an  element  in  the  building  up,  as  well  as  in 
the  tearing  down  of  tissue.  There  are  emergencies  in  which  the 
oral  surgeon  or  physician  desires  to  invoke  its  aid,  and  he  some- 
times deliberately  incites  its  action.  But  to  reach  the  success  at 
which  he  aims  he  must  be  able  to  control  and  limit  it,  to  impede 
its  action  here  and  to  further  its  energ\-  there,  and  at  all  times  to 
check  it  before  it  shall  reach  a  degenerative  or  infective  stage. 
Unless  the  practitioner  has  a  fair  comprehension  of  this  important 
process,  he  will  always  be  at  work  in  the  dark,  and  his  treatment 
of  most  diseased  oral  conditions  will  be  wholly  empirical  and 
experimental.  The  student  will  not  be  able  intelligently  to  investi- 
gate any  of  the  disorders  to  which  he  hopes  successfully  to 
minister,  without  a  careful  preliminary  study  of  inflammation. 


26 


ORAL    PATHOLOGY   AND   PRACTICE. 


The  most  advanced  of  modern  pathologists,  while  they  have 
extended  the  field  of  observation,  have  materially  simplified  the 
nomenclature.  They  recognize  many  added  phases  which  the 
inflammatory  process  may  assume,  but  in  the  light  of  the  most 
modern  bacteriological  research  they  acknowledge  but  one  dis- 


Fig.  7. 


e.D. 


Od.- 


^'.  T.- 


B.V.-- 


■N.I^ 


m\m 


i.jdk.jrj 


Section  of  a  Too  ih-Pui.p.     (Burchard,  after  Rose  and  Gysi. ) 

£.1^,  Principal  bloodvessels.     C,  Capillaries.     JV.T,  Principal  nerve  trunk.    7V.-F,  fibrillse 
of  nerves.     Od,  Odontoblasts.     S.D,  Secondary  dentine.     C.G,  Masses  of  calco-globulin. 


tinct  form,  that  being  the  infective.  Up  to  the  point  of  invasion  by 
septic  organisms  and  the  commencement  of  the  deteriorative  or 
destructive  process,  they  denominate  the  condition  one  of  hyperemia. 
Until  disease  germs  are  communicated  they  declare  there  can 
be  no  breaking  down  of  tissue,  or  of  the  elements  of  tissue.  There 
may  be  failure  to  organize  the  embryonal  constituents,  but  the 


inflammation:     its  general  characteristics.  27 

disorganization  of  that  which  has  once  been  constructed  can  only 
take  place  after  infection.  Hence,  according  to  their  views,  all  of 
the  early  symptoms  and  phenomena  which  are  usually  classed  as  a 
part  of  the  inflammatory  process  belong  to  the  distinct  condition 
hyperemia,  and  are  indicative  only  of  a  local  plethora,  or  congestion. 

In  this  conception,  and  according  to  this  nomenclature, 
inflammation  is  essentially  a  destructive  process,  and  its  initial 
point  is  the  beginning  of  the  disorganization  of  tissue.  This 
hypothesis  emancipates  us  from  the  old  and  absurd  nomenclature, 
under  which  every  different  phenomenon  exhibited  by  what  must 
necessarily  be  a  single  process  was  given  a  separate  name  and 
classed  as  a  distinct  form  of  inflammation.  Some  writers  have 
specified  as  many  as  fifteen  kinds  of  this  process,  and  treated  each 
as  a  separate  pathological  condition.  There  has  been  no  identity 
of  view,  and  no  harmony  in  description  or  terminology.  There 
has  been  no  universally  accepted  theory  which  might  be  adopted, 
but  each  pathologist  has  been  in  one  sense  a  law  unto  himself, 
and  has  instructed  according  to  his  own  views. 

If  the  most  modern  hypothesis  shall  be  generally  adopted, 
there  is  no  doubt  that  it  will  materially  simplify  pathological 
instruction,  and  reduce  to  a  comprehensible  system  much  that 
has  heretofore  been  incongruous  and  unintelligible.  But  in  the 
preparation  of  a  book  to  be  used  in  teaching,  extreme  views  should 
not  precipitately  be  adopted.  They  are  not  likely  to  be  in  har- 
mony with  the  teachings  of  the  other  departments  of  a  school, 
they  are  in  conflict  with  instruction  already  given  and  with 
preconceived  ideas,  and  until  they  can  be  generally  accepted  tend 
to  produce  confusion  in  the  mind  of  the  student,  and  are  preju- 
dicial to  that  unity  in  theory  and  consecutiveness  in  thought 
which  are  essential  to  good  tuition.  It  is  infinitely  better  that 
the  student  in  college  should  be  given  but  one  hypothesis,  rather 
than  a  number  of  conflicting  theories.  When  he  is  familiar  with 
that,  he  may  in  practical  life  leave  its  limitations  and  modifications, 
and  become  acquainted  with  other  views. 

This  work,  then,  while  fully  recognizing  the  reasonableness 
of  the  most  modern  theories  concerning  inflammation,  will  not 
fully  adopt  their  nomenclature,  but  will  follow  the  usually  accepted 
views,  modified  to  a  certain  extent  by  the  indisputable  facts  estab- 
lished by  the  most  modern  research. 


28 


ORAL    PATHOLOGY    AND    PRACTICE. 


:o- 


But,  while  making  this  concession,  it  must  not  be  understood 
that  it  accepts  or  approves  the  infinitesimal  division  of  that  which 
is  really  indivisible,  and  that  it  will  consider  every  accidental  phase 
of  that  pathological  condition  which  is  denominated  inflammation 
as  a  distinct  and  separate  disease.  There  can  be  no  essential  dif- 
ference between  an  inflammation  of  the  pulp  of  a  tooth,  or  its 
pericementum,  and  the  same  degenerative  process  in  the  tissue  of 
the  tongue,  or  the  brain,  or  the  lungs.  It  is  true  that  each  may 
assume  certain  definite  phases,  and  may  exhibit  varying  phenomena 
or  symptoms,  but  these  are  induced  by  structural  modifications, 
or  by  differences  in  the  environment  and  surrounding  conditions. 
The  pathology  is  essentially  identical ;  the  same  causes  produce  it 
in  either  case,  and  though  we  may  denominate  the  special  phe- 
nomena as  exhibited  pulpitis,  pericementitis,  glossitis,  or  pneu- 
monitis, according  to  the  location,  we  should  not  look  upon  them 
as  separate,  distinct,  and  diverse  diseases.  The  same  general 
treatment  will  be  pursued  in  all  cases ;  the  same  remedies  are  appli- 
cable, modified  only  by  the  modifying  conditions  or  surroundings. 
Hence  in  the  general  study  of  inflammation  we  should  consider  it 
as  always  the  same  degenerative  process,  and  carefully  avoid  the 
^unnecessary  multiplication  of  terms. 

Inflammation  may  be  defined  as  a  disturbance  of  nutrition  in 
a  tissue  or  organ,  primarily  characterized  by  hyperemia  and  accom- 
panied by  certain  definite  symptoms.  Its  proximate  cause  is  irri- 
tation of  some  kind,  producing  nervous  shock,  either  direct  or 
reflex,  which  is  conveyed  through  the  vaso-motor  system  to  the 
capillaries  and  first  manifested  by  changes  in  those  vessels,  thus 
modifying  the  nutritive  blood  current.  That  the  student  may  com- 
■prehend  this,  it  is  necessary  clearly  to  define  some  of  the  terms 
used,  and  to  indicate  in  what  sense  they  are  employed. 

Plethora  is  that  state  in  which  there  is  an  abnormal  fulness  of^ 
the  bloodvessels;  a  superabundance  of  blood ;  an  undue  increase 
in  the  entire  mass  of  the  blood  in  the  system. 

Anemia  is  the  converse  of  this.     It  is  a  state  in  zvhich  there  is  a 
^"deficiency  of  the  blood  as  a  whole,  but  especially  a  lack  of  the  red 
blood  corpuscles.     It  is  therefore  a  condition  of  depression  of  the 
tone  of  the  system,  and  of  enfeebled  nutritive  ability. 

Hyperemia  is  a  local  plethora  or  congestion  of  blood.     Its  special 
seat  is  in  the  capillaries. 


INFLAMMATION 


ITS    GENERAL    CHARACTERISTICS. 


29 


Ischemia  is  a  local  anemia.  It  implies  a  lack  of  nutrition  in  a 
part,  as  anemia  does  in  the  general  system,  because  the  supply  of 
blood  is  for  some  reason  insufficient. 

Hyperemia  implies  an  alteration  in  the  velocity  of  the  current 
of  the  blood  in  both  veins  and  arteries.  It  also  includes  a  variation 
of  the  bloodvessels  in  their  character  or  tone,  their  nutritive  power 
being  modified.  There  is  a  change  in  the  condition  of  the  coats  of 
the  smaller  arteries  and  veins ;  they  assume  a  state  either  of  tense- 
Fin.  ?. 


Cementum,  showing  the  Cementum  Corpuscles,  or    Lacunae,  with  the  Canaliculi. 

(Broomell.) 

ness  or  laxity  that  is  not  normal  to  them.  They  become  turgescent. 
The  color  of  the  blood  in  the  veins  is  changed  by  modifications  of 
nutrition.  It  is  no  longer  of  a  dark  or  venous  color,  but  more  nearly 
approaches  a  bright  arterial  hue,  due  to  its  inability  to  perform  its 
true  function  and  exchange  its  oxygen  for  the  carbon  dioxide  that 
is  the  result  of  the  degenerations  of  tissue  due  to  wear.  There  is  a 
partial  obstruction  of  the  current  in  the  arterioles,  and  they  may 
even  begin  to  pulsate  with  the  larger  arteries.  Both  veins  and 
arteries  become  distended  with  the  increased  flow  of  blood.     The 


30  ORAL    PATHOLOGY   AND    PRACTICE. 

blood  corpuscles  are  greatly  increased  in  number  and  modified  in 
tone. 

If  the  irritation  that  has  produced  this  condition  in  the  tissues 
is  not  continued,  the  disturbance  will  be  but  temporary,  and  will 
soon  subside.  The  system  recovering  from  the  nervous  shock,  the 
bloodvessels  will  soon  regain  their  normal  tone,  the  vascular  fluid 
will  begin  to  flow  in  its  wonted  manner,  the  congestion  of  the 
capillaries  will  be  relieved,  and  the  hyperemic  condition  will  pass 
away. 

It  has  already  been  affirmed  that  it  is  the  nervous  shock  pro- 
duced by  the  action  of  some  irritant  which  induces  the  change  in 
the  condition  of  the  arteries  and  veins  that  accompanies  active 
hyperemia.  Technically  it  is  not  the  bullet  in  the  heart  that  kills ; 
it  is  the  nervous  shock  caused  by  the  irritating  bullet.  The 
knife  stab  may  injure  certain  tissues  that  are  not  vital;  but  in  so 
doing  it  may  produce  a  nervous  impression  that  is  so  profound  as 
materially  to  interfere  with  the  processes  of  life  which  are  vital, 
function  may  cease,  and  that  is  death.  It  was  not  the  wound  that 
killed,  but  the  markedly  depressing  influence  which  it  induced  upon 
organs  themselves  untouched.  It  is  necessary  to  keep  this  distinc- 
tion carefully  in  mind  in  the  consideration  of  inflammation. 

Shock  may  be  produced  by  either  direct  or  reflex  nervous. action, 
and  it  may  be  immediate  or  delayed. 

By  direct,  zve  mean  the  irritation  that  is  produced  by  actual  injury 
to  the  terminal  nervous  filaments  themselves.  Thus  a  blow  upon  the 
cheek  will  induce  a  redness,  or  hyperemia  in  the  capillaries  of  the 
tissue  that  received  the  irritation,  and  whose  nerve  filaments  were 
really  harmed  or  shocked  by  the  impact. 

By  reflex  nervous  action,  we  mean  that  in  which  the  impulse  is 
reflected,  or  carried  by  one  set  of  nerves  to  another  set,  thus  pro- 
ducing its  effect  at  a  distance  from  the  seat  of  irritation.  The  influ- 
ence of  an  irritant  may  be  carried  by  an  afferent,  or  sensory  nerve, 
to  some  great  center,  where  it  will  be  transmitted  to  an  efferent,  or 
motor  nerve,  and  the  stimulus  carried  along  its  course  until  it 
reaches  the  tissue  supplied  by  it,  and  it  may  be  upon  this  that  the 
characteristic  effect  will  be  indicated.  Or  the  effect  of  the  irritating 
agent  may  be  received  by  one  afferent  nerve  and  reflected  to  another 
of  the  same  system,  the  subjective  sensation,  with  the  local  effects, 
thus  being  made  manifest  at  some  distance  from  the  point  of  injury. 


INFLAMMATION  :       ITS    GENERAL    CHARACTERISTICS. 


31 


The  blush  that  is  brought  to  the  cheek  of  the  sensitive  young  maiden 
by  an  indehcate  remark  is  the  same  kind  of  transient  hyperemia  that 
is  produced  by  a  blow  of  the  hand.  Yet  in  the  former  case  there  is 
no  real  impact,  no  positive  injury,  no  actual  lesion  of  any  kind. 
But  the  Jiyperemia  will  probably  be  more  pronounced  and  marked 
than  when  the  nervous  action  is  direct.  The  face  will  blanch 
under  the  influence  of  fear,  when  no  direct  impact  could  produce 
this  effect.  The  hair  will  stand  erect  through  reflex  action  caused 
by  intense  alarm  or  terror,  a  state  that  no  voluntary  action  could 


Fig.  9. 


Structure  of  Dentine,  showing  the  Branching  of  the  Dentinal  Tubuli. 


bring  about.  People  sometimes  drop  dead  at  the  communication  of 
profoundly  affecting  news,  which  acts  in  a  reflex  manner.  Indeed, 
instant  functional  cessation  and  death  are  more  complete  and  fre- 
quent in  cases  of  shock  from  reflex  than  from  direct  injuries.  The 
influence  of  external  and  surrounding  impressions  upon-sick  people 
will  not  infrequently  completely  neutralize  the  effect  of  medicinal 
agents. 

Profound  anesthesia  cannot  readily  be  obtained  in  people  with 
unusually  responsive  nerves,  unless  external  irritation  and  inter- 
ference is  cut  off.  It  becomes  necessary  in  such  instances  to  remove 
all  exciting  causes  and  establish  complete  quietness  about  them. 


32  ORAL    PATHOLOGY    AND    PRACTICE. 

It  would  appear,  then,  that  of  the  sources  of  irritation  that  may 
produce  hyperemic  conditions,  those  that  are  derived  through  reflex 
nervous  action  are  the  more  important,  and  should  be  most  carefully 
guarded  against. 


CHAPTER  VII. 


CHANGES  ATTENDING  THE  INFLAMMATORY 
CONDITION. 

The  changes  in  the  veins  and  arteries  that  induce  a  condition  of 
hyperemia  are  produced  through  the  vaso-motor  nerves.  These 
are  derived  both  from  the  cerebro-spinal  and  the  great  sympa- 
thetic systems.  They  are  the  non-medullated  terminal  filaments 
whose  special  function  it  is  to  govern  and  keep  in  proper  relation 
the  coats  of  the  bloodvessels  to  which  they  are  distributed.  Upon 
the  larger  vessels  they  form  intricate  plexuses,  sending  out  single 
filaments,  or  bundles  of  filaments,  which  twine  about  the  vessels, 
penetrate  their  external  coats,  and  are  principally  distributed  to  the 
muscular  tissue  of  the  vessel,  and  by  their  action  in  contracting  or 
relaxing  the  artery  or  vein  they  govern  the  amount  of  the  blood- 
flow. 

There  are  presumably  two  kinds  of  nerves  in  the  vaso-motor 
system,  one  being  the  constrictors  and  the  other  the  dilators.  It 
will  readily  be  seen,  then,  that  either  may  be  excited  and  the  caliber 
of  the  vessel  modified  accordingly.  Nor  is  the  amount  of  blood 
necessarily  and  completely  gauged  by  the  question  as  to  whether 
it  is  the  dilators  or  the  constrictors  that  are  excited  to  action.  There 
may  be  a  lessening  of  the  caliber  but  a  retention  of  the  elasticity  of 
the  muscular  fibers  that  will  result  in  a  great  increase  of  the  velocity, 
and  this  may  have  a  tendency  to  wash  away  anv  obstructions  in  the 
blood  channels.  On  the  other  hand,  there  may  be  a  dilatation  with 
a  loss  of  tone  and  a  complete  rigidity  of  the  muscular  coats  that 
will  eventuate  in  a  reduction  of  the  velocity  as  well  as  in  the  amount 
of  blood  conveyed. 

There  may  be  a  contraction  of  the  vessel,  with  a  condition  of 
such  tonicity  as  will  greatly  augment  the  velocity  of  the  circula- 
tory fluid,  or  there  may  be  almost  a  complete  stagnation  of  blood 
in  a  greatly  relaxed  artery  or  vein.     Niagara  river  at  its  head  is 


CHANGES    ATTENDING    THE    INFLAMMATORY    CONDITION.  33 

nearly  two  miles  wide.  At  the  Whirlpool  rapids  below  the  Falls  it 
is  contracted  into  a  narrow  channel  but  a  very  few  hundred  yards 
across.  Yet  a  somewhat  larger  amount  of  water  pours  through  the 
gorge  of  Niagara  than  flows  past  Buffalo.  Lake  Ontario  is  but  a 
great  expansion  of  Niagara  river,  augmented  by  tributary  streams. 
At  Buffalo  the  Niagara  is  a  smooth  and  steadily  flowing  current 
which  subserves  a  thousand  useful  purposes.  The  Whirlpool  rapids 
is  a  tumultuous,  riotous  torrent,  suggestive  only  of  death  and  de- 
struction. Lake  Ontario  is  a  sluggish,  lethargic  expanse,  almost 
without  current.  Under  the  influence  of  the  vaso-motor  nerves, 
and  according  to  their  tonicity  or  lack  of  it,  the  blood  current  in  the 
capillaries  may  be  a  steadily  moving,  gentle,  nutritive  current,  a 
violent,  turbulent,  destructive  torrent,  or  a  phlegmatic,  stagnant 
expansion. 

It  may  readily  be  seen,  then,  that  the  tone  of  the  walls  of  the 
vessels  has  very  much  to  do  with  the  blood  supply.  Through  the 
reaction  of  the  vaso-motor  nerves,  the  very  character  of  the  coats 
of  the  capillaries  may  be  materially  modified,  so  that  instead  of 
retaining  their  contents  they  allow  an  undue  emission  through  the 
meshes.  The  different  coats  may  become  so  relaxed  that  through 
their  walls  the  red  or  the  white  blood  corpuscles,  or  the  serum  of  the 
blood,  may  readily  exude,  and  so  pass  out  into  the  surrounding 
tissues,  infiltrating  them  and  producing  certain  symptoms  which 
attend  the  condition  that  is  commonly  called  the  inflammatory 
state.  All  these  changes  must  be  massed  in  the  consideration  of 
the  inflammatory  process. 

The  first  stage  is  hyperemia,  or  an  increased  blood  supply, 
through  modHication  of  the  caliber  of  the  coats  of  the  bloodvessels. 

The  second  stage  consists  in  the  further  changes  in  the  condition 
of  the  coats  of  the  vessels,  by  which  they  become  so  modified  as  no  longer 
perfectly  to  retain  all  their  contents. 

The  third  stage  is  the  modification  produced  in  the  tissues 
through  the  extruded  contents  of  the  bloodvessels,  for  the  elements 
having  once  passed  out  cannot  enter  them  again,  but  must  be  other- 
wise disposed  of.  This  stage  necessarily  includes  the  degenerative 
processes  taking  place  in  the  products  of  inflammation  which  result 
from  infection. 

It  should  be  apprehended  that  the  mere  change  in  the  caliber^ 
of  the  vessel  forms  no  necessary  part  of  the  inflammation,  whicl 

4 


34 


Or.AL    PATHOLOGY   AND    PRACTICE. 


may  terminate  with  the  simple  hyperemia.  But  the  second  change, 
that  in  the  vessels,  which  so  modifies  them  that  they  no  longer 
retain  their  contents,  produces  a  more  profound  impression  and 
materially  affects  the  tissues  nourished  by  them.  When  the 
extravasated  matter  becomes  infected  with  pathogenic  or  pyogenic 


Fig 


Enamel  Highly  Magnified,   showing  the  Characteristic  Prisms. 
(J.  L.  Williams.) 

micro-organisms  that  impression  is  intensified,  and  degenerative 
processes  are  set  up.  This  is  an  active  state  of  inflammation,  in 
which  all  the  nutritive  processes  of  the  part  are  engaged. 

There  are  certain  symptoms  that  are  peculiar  to  inflammation 
and  which  always  attend  it  in  a  greater  or  less  degree.  They  are 
heat,  redness,  swelling,  pain,  and  usually  a  general  febrile  condition. 


a 


k^ 


K^ 


^cji/yi/Oh^ 


CHANGES    ATTENDING   THE   INFLAMMATORY    CONDITION.  35 

The  violence  of  these  will  depend  upon  the  gravity  of  the  disturb- 
ance and  the  character  of  the  tissue  affected.  Other  things  being 
equal,  the  more  vascular  it  is,  the  greater  the  blood  supply,  the 
more  pronounced  will  be  the  symptoms. 

The  first  of  these,  heat,  is  due  to  a  number  of  factors.  The 
deeper  portions  of  the  body  have  a  higher  temperature  than  those 
that  are  superficial  and  are  exposed  to  external  cooling  influences. 
When  the  blood  quickly  reaches  the  periphery  it  will  lose  less  of  its 
vital  heat  than  when  it  makes  its  way  more  gradually.  Hence,  in 
the  increased  velocity  of  inflammation,  the  surface  has  more  of  the 
heat  of  the  internal  portions  of  the  body. 

Again,  this  very  velocity  generates  a  certain  amount  of  heat  by 
the  increased  friction.  There  is  also  some  increased  oxidation, 
and  this  adds  to  the  higher  temperature.  All  of  these  factors 
together  account  for  the  increased  local  heat  of  inflammation. 

The  redness  is  due  to  the  hyperemic  condition,  the  increased 
amount  of  blood  in  the  part,  and  the  unchanged  color  of  the  venous 
circulation.  The  intensity  of  the  change  will  depend  upon  several 
factors.  The  amount  of  the  local  disturbance,  the  thickness  of  the 
siiperiniposed  tissues  and  their  degree  of  translucency,  will  all  have 
an  influence.  Persons  with  thin,  transparent  skins  show  the  super- 
ficial hyperemic  condition  much  more  plainly  than  others. 

The  swelling  is  the  effect  of  the  diapedesis,  or  escape  of  the 
elements  of  the  blood  through  the  walls  of  the  vessels,  because  of 
their  changed  condition  under  the  irritation  manifested  through  the 
vaso-motor  nerves.  The  tissues  are  thus  infiltrated  and  distended. 
The  amount  of  this  dilatation  or  expansion  will  depend  upon  the 
nature  of  the  tissue  in  which  it  takes  place,  and  upon  the  character 
of  the  functional'  disturbance. 

The  pain  is  the  effect  produced  upon  the  terminal  nervous  fila- 
ments by  the  deranged  condition,  and  the  pressure  of  the  exudate. 
Sometimes  this  will  be  of  a  throbbing  character,  due  to  the  pres- 
sure exerted  by  the  arterioles  at  each  heart  contraction,  or  systole, 
upon  the  already  irritated  and  sensitive  terminal  nerve  filaments. 
Boring  pains  are  usually  connected  with  inflammations  of  bone 
tissue.  Lancinating  pains  ordinarily  accompany  acute  swellings, 
and  are  indicative  of  a  determining  abscess.  Soreness  is  due  to  the 
^formation  of  an  abscess  cavity  in  a  very  sensitive  tissue  or  organ, 
'hat  of  a  boil,  which  is  an  instance  of  suppurative  inflammation,  is 
proverbial. 


36  ORAL    PATHOLOGY   AND    PRACTICE. 

The  general  fever  is  the  result  of  the  sympathy  of  other  organs 

with  that  which  is  directly  affected.     It  is  the  office  of  the  nervous 

system  to  preserve  the  equilibrium  of  the  various  functions  of  the 

body.     When  this  is  disturbed  by  an  aberration  existing  in  any 

organ,  all  the  others  suffer  to  a  greater  or  less  degree,  and  thus  is 

produced  a  general  feeling  of  malaise  or  discomfort.  ' 

/"         The  causes  which  excite  an  inflammatory  condition  are  divided 

I     into  predisposing  and  exciting. 

\  Predisposing  causes  are  special  conditions  of  the  body  which 

j      render  the  organs  or  tissues  more  liable  to  take  on  the  pathological 

\    conditions.     In  the  presence  of  predisposing  causes,  comparative! 

slight  irritation  may  result  in  serious  disturbances.     A  state  of 

atony,  or  asthenia,  or  general  debility,  reduces  the  resistive  force  of 

the   tissues   and   promotes   the   invasion   of   disease.     Anemia   is 

another  predisposing  cause,  the  poverty  of  the  blood,  or  the  lack  of 

certain  of  its  elements,  seriously  interfering  with  that  nutrition 

which  must  maintain  the  general  tone. 

{The  exciting  causes  of  inflammation  are  very  many,  and  include 
whatever  may  produce  shock,  such  as  cold,  heat,  traumatism  or 
injuries,  etc.  A  common  cold  is  an  inflammation  induced  by  sub^ 
jecting  one  part  of  the  body  to  a  sudden  diminution  of  its  tem- 
perature, and  thus  disturbing  the  general  nervous  equilibrium  or 
tone.  Many  chemical  substances  are  nervous  irritants,  either 
through  direct  or  reflex  action.  Poisons  act  in  this  way,  and  these 
include  the  stings  of  bees,  the  bites  of  many  insects,  and  the  pecu- 
liar effect  of  certain  vegetables,  such  as  poison  ivy  and  oak. 

Many  of  the  pathogenic  micro-organisms  induce  a  state  of  inflam- 
mation through  their  growth  in  the  system.  All  lesions,  wounds,  and 
injuries  give  a  shock  that  is  more  or  less  profound,  and  thus  bring 
about  inflammatory  conditions. 

A  cachectic  state,  or  dyscrasia,  is  one  either  of  disturhed  gen- 
eral nutrition  or  of  local  degeneration,  that  makes  the  organs 
liable  to  inflammation,  as  in  gout,  calculus,  etc. 

It  has  already  been  affirmed  that  a  nervous  shock  that  affects 
the  vaso-motor  system  may  so  change  the  condition  of  the  blood- 
vessels as  to  permit  the  escape  of  a  portion  of  their  contents.  John 
Hunter  recognized  the  intimate  connection  of  the  blood  current 
with  inflammatory  processes,  and  declared  that  hyperemia  and  con- 
gestion were  their  initiative  stages.     Less  than  thirty  years  ago, 


FURTHER    DEGENERATIVE    CHANGES.  37 

Cohnheim  published  the  results  of  a  series  of  observations  that 
gave  the  world  a  new  insight  into  the  pathological  changes  that  ac- 
company this  disturbed  condition,  especially  in  the  earlier  modifica- 
tions. Other  pathologists  have  carried  the  explorations  further, 
and  some  of  them  have  dissented  from  a  part  of  the  conclusions  of 
Cohnheim,  but  his  general  deductions  are  accepted  as  correct  by 
most  pathologists. 


CHAPTER  VIII. 

FURTHER  DEGENERATIVE  CHANGES. 

If  the  mesentery  of  a  frog  is  exposed  to  the  air  and  placed 
under  a  microscope,  it  will  be  seen  that  the  flow  of  blood  in  the 
capillaries  is  greatly  augmented.  They  are  distended,  and  many 
that  had  been  invisible  are  by  this  dilatation  brought  into  view. 
The  leucocytes,  or  white  blood  corpuscles,  are  gradually  increased 
in  number.  Regions  in  which  there  normally  appears  only  an 
occasional  one,  soon  become  thronged  with  them.  The  increased 
velocity  of  the  current  lasts  but  a  short  time,  when  the  flow  begins 
to  be  retarded,  and  is  soon  slower  than  the  normal,  the  distention 
still  remaining.  A  partial  stagnation  succeeds,  and  the  white 
corpuscles  begin  to  accumulate  in  the  small  veins  and  arteries,  and 
show  a  tendency  to  cling  to  the  walls.  They  are  swept  back  into 
the  lessening  current,  but  soon  find  another  point  of  attraction,  and 
finally  remain  attached  to  the  lining  surface.  They  soon  become 
so  enormously  increased  that  the  inner  surface  of  the  vessels  is 
completely  covered  with  them.  In  the  capillaries  and  arteries  the 
white  corpuscles  are  mingled  with  the  red,  and  do  not  accumulate 
in  such  great  numbers,  but  in  small  veins  they  seem  to  have  become 
separated  from  the  red  and  to  cling  in  greater  numbers. 

Soon  they  begin  to  alter  their  appearance,  and  to  exercise 
their  peculiar  ameboid,  or  spontaneous  change-of-form  movements. 
(See  Fig.  ii.)  The  vessel  wall  remaining  distended,  after  a  little 
time  there  is  observed  upon  its  external  surface  a  minute  protuber- 
ance, which  momentarily  increases,  the  cell  opposite  upon  the 
internal  wall  correspondingly  diminishing,  until  it  is  seen  that  the 
whole  of  the  jelly-like  protoplasmic  leucocyte  has  penetrated  the 


38 


ORAL    PATHOLOGY   AND   PRACTICE. 


walls  and  been  extruded  upon  the  periphery.  Coincidental  with 
the  changed  condition  of  the  vessel  walls,  other  of  the  contents  have 
passed  through  and  invaded  the  surrounding  tissues.  The  leuco- 
cytes have  been  considered  as  the  active  agents  of  repair,  themselves 
forming  the  initial  or  germinating  point  in  the  organization  of  the 
plastic  exudate  into  tissue.  This  hypothesis  seems  most  consistent 
with  known  facts,  and  offers  a  ready  explanation  of  some  phe- 
nomena not  otherwise  comprehensible. 

It  is  but  proper  to  say  that  this  theory  is  not  accepted  by  some 
histologists  and  embryologists,  who  consider  the  leucocytes  but  as 
scavengers  for  the  removal  of  offensive  matter. 

Fig.  II. 


Leucocytes,  showing  Ameboid  Movements. 

a,  b,  c,  d,  Pseudopodia.    e.  Constriction  when  passing  through  the  coats  of  a  bloodvessel. 

(Very  much  enlarged.) 

That  the  leucocytes  have  a  digestive  power,  appropriating 
bacteria,  has  been  shown  by  a  number  of  observers.  They  may 
also  be  useful  in  consuming  portions  of  broken-down  tissue,  and 
hence  assist  in  the  absorption  of  blood-clots,  exudations,  etc.  But 
that  this  is  their  sole  office  does  not  seem  congruous  or  compatible 
with  demonstrated  truths,  and  it  is  not  accepted  in  this  connection. 

The  number  of  leucocytes  is  notably  increased  during  inflam- 
mation. They  may  be  seen  to  gather  in  great  numbers  in  the 
smaller  vessels,  and  they  migrate  in  profusion  into  the  surrounding 
tissues.  Their  origin  is  yet  in  dispute.  It  was  formerly  held  that 
their  multiplication  was  due  to  increased  cell  proliferation  or  for- 
mation under  the  stimulus  of  the  inflammatory  process.  But  Von 
Recklinghausen  found  in  connective  tissue  two  kinds  of  cells, 
which  he  called  the  fixed  and  the  wandering.  The  former  he  says 
are  stationary  among  the  fibers  of  the  intercellular  substance,  and 


FURTHER    DEGENERATIVE    CHANGES.  39 

are  round,  or  spindle-shaped.  In  addition  to  these  he  observed 
other  cehs,  in  all  respects  resembling  the  leucocytes,  which  take  on 
spontaneous  changes  of  shape  by  means  of  the  extension  of  a 
portion  of  their  jelly-like  substance  (pseudopodia — false  feet),  such 
as  are  characteristic  of  the  ameba,  and  hence  called  ameboid  move- 
ments. By  means  of  these  mutations  they  constantly  changed 
their  location,  passing  through  the  meshes  of  the  lymph  canals, 
entering  from  the  blood  and  escaping  through  the  lymphatics,  thus 
keeping  up  a  constant  circulation.  In  normal  tissues  they  were 
few  in  number,  but  in  the  presence  of  irritation  or  inflammation 
they  were  inordinately  multiplied. 

This  is  the  generally  accepted  theory  of  to-day.     The  wander- 
ing cells  of  Von  Recklinghausen,  or  the  white  blood  corpuscles, 
or  leucocytes,  which  even  in  entire  health  are  escaping  through  the 
walls  of  the  bloodvessels   in  small   nvimbers,  by   means   of   their 
ameboid  movements  may  traverse  the  tissues  through  the  lymph 
channels  until  they  are  finally  extruded.     Their  probable  generation 
is  in  the  lymph  glands  or  nodes,  the  spleen,  etc.,  and  in  inflammatory 
conditions  they  are  enormously  increased,  and  are  carried  by  the 
blood  to  the  disturbed  territory,  whence  they  readily  pass  into  the 
tissues  through  the  changed  condition  of  the  vessel  walls.     Their 
multiplication  in  an  inflamed  tissue  is  in  proportion  to  the  violence 
of  the  disturbance. 
/^         Corresponding  to  this  increase  in  the  number  of  the  white 
I    blood  corpuscles  in  the  tissues  is  the  extravasation  from  the  blood- 
)   vessels  of  the  fluid  portions,  or  the  blood  plasma.     The  ""fibrinogen 
X  which  this  contains,  coming  in  contact  with  the  paraglobulin  and 
ferment  of  the  leucocytes  under  their  changed  condition,  fibrin  is 
formed  and  the  lymph  is  coagulated  or  fixed  in  the  tissues.     The 
product  thus  formed,  with  the  emigrated  blood  cells,  composes  that 
which  is  known  as  the  "plastic  exudate"    (plastic  or  organizable 
lymph,  fibrinous  lymph),  and  it  is  the  progressive  or  degenerative 
changes  in  this  substance  that  constitute  the  further  phenomena  of 
inflammation. 
/        The  plastic  exudate  once  having  been  formed  in  the  tissues,  it    \ 
j  may  assume  such  a  complete  fibrination,  such  an  entire  conversion   / 
into  a  dense  compact  fibrin,  as  to  produce  that  vsrhich  is  called  an   / 
induration.     This  at  times  assumes  to  the  fingers  almost  the  hard;^ 
\  ness  of  bone.     In  inflammation  of  the  tissues  about  the  jaws  it  is 


40  ■  ORAL    PATHOLOGY    AXD    PRACTICE. 

not  infrequently  mistaken  by  the  novice  for  bone,  and  a  wrong 
diagnosis  is  accordingly  made.  It  may  be  immovable,  without 
special  sensation  or  pain,  and  apparently  closely  attached  to  the 
osseous  tissue.  In  this  form  the  plastic  exudate  is  persistent  and 
indolent  in  its  character,  and  does  not  readily  degenerate  nor 
assume  a  progressive  aspect.  It  may  disappear  under  the  slow 
process  of  gradual  resorption,  or  it  may  eventually  break  down. 


CHAPTER  IX. 
THE  PRODUCTS  OF  INFLAMMATION. 

(Tlie  methods  by  which,  the  plastic  exudate,  or  the  coagulable  or 
fibrous  lymph,  and  the  remaining  products  of  inflammatory  condi- 
tions may  be  disposed  of.  are  by  (1)  Resolution,  (2)  Building  up, 
(3)  Tearing  down.  j 

Resolution  means  the  faking  up  of  the  products  by  the  absorbents, 
and  their  disposition  through  the  lymphatic  system.  There  is  a 
cessation  of  irritation,  the  bloodvessels  return  to  their  normal 
condition,  exudation  ceases,  and  there  is  a  gradual  return  to  a 
true  physiological  state,  as  there  is  when  hyperemia  alone  exists 
and  the  disturbance  does  not  extend  to  the  point  of  active  inflam- 
mation. 

Building  np  of  tissue  means  that  the  plastic  exudate  has  been 
by  regular  progressive  changes  organized  into  tissue  of  an  embryonic 
character.  The  methods  of  this  metamorphosis  are  by  first,  second, 
and  third  intention. 

First  Intention. — This  implies  a  regular  progression  from  the 
commencement,  z^'ifliout  any  degenerative  changes  zvhatever.  No 
pus  is  formed,  nor  is  there  infection  by  micro-organisms.  The 
term  "healing  by  first  intention"  is  usuall}^  applied  to  wounds, 
either  traumatic  or  surgical,  especially  to  those  of  an  incised 
character.  If  the  gaping  produced  by  the  elasticity  of  the  tissues 
is  closed,  and  the  severed  parts  brought  into  nice  coaptation, 
either  by  stitches,  adhesive  plaster,  or  finger  manipulation,  the 
fibrin  that  is  formed  by  the  plastic  exudate  agglutinates  or  cements 
them  together,  and  union  without  any  violent  or  disruptive 
inflammation  may  ensue.     This  can  only  be  secured  by  thoroughly 


TIfK    l'Rf)|)UCTS    OF    1  N  FLA  M  .\I  A'l  ION. 


41 


aseptic  conditions,  and  it  is  this  at  which  all  surgeons  aim  in  their 
treatment  after  operations. 

Grranulation,  or  Second  Intention. — I'liis  is  the  building  up  of 
the  tissue,  or  the  organization  of  the  exudate  by  means  of  papillcc, 
or  grain-like  grozvths,  that  spring  up  from  the  base  of  healing 
zvounds.     It  is  a  progression  cell  by  cell,  instead  of  organization 

Fig.   12. 


Granulating  Tissuh,  .showing  the  Capillary  Loops.    (After  Riiidfleisch.) 

a,  Dead  leucocytes.   6,  Granulating  tissue,   c,  Commencing  metamorphosis  of  granulations 

into  a  fibrous  structure. 

more  in  mass.  Capillary  loops  are  formed  in  the  extravasated 
plasma,  which  as  it  is  poured  out  will  be  found  shielded  by  a  kind 
of  transparent  glistening  film,  that  protects  it  until  the  lost  tissue 
has  been  restored  and  the  skin  shall  have  been  formed  over  it. 
This  new  growth  is  known  as  granulation  tissue,  and  is  always 
of  a  cicatricial  or  elementary  character.  The  new  formation  is 
primarily  of  the  connective  tissue  variety,  and  is  subsequently 
modified  into  that  of  which  it  forms  a  part.      (See  Fig.  12.) 


42  ORAL    PATHOLOGY   AND    PRACTICE. 

The  organization  of  the  tissue,  when  it  proceeds  without  any 
degenerative  processes,  may  be  cHnically  studied  in  the  socket 
from  which  a  tooth  has  been  extracted.  The  cavity  will  at  first 
be  found  filled  with  coagulated  blood,  which  effectually  seals  the 
mouths  of  the  ruptured  vessels.  Within  a  very  few  days  at  the 
most,  this  will  have  been  sloughed  away  or  materially  modified,  and 
the  socket  of  the  root  will  be  found  occupied  by  a  kind  of  trans- 
lucent, jelly-like  substance,  which  is  very  easily  wiped  away  with  a 
pledget  of  cotton.  If  it  is  left  undisturbed  a  short  time  longer,  it 
assumes  a  firmer  consistence  and  becomes  opaque  and  of  a  whitish 
color.  This  is  the  plastic  exudate  that  has  been  effused.  It  now 
cuts  like  gelatin,  and  has  the  same  general  appearance.  Another 
day,  and  if  it  be  divided  with  an  excavator  or  the  point  of  a  sharp 
bistoury,  a  minute  drop  of  blood  will  ooze  out.  This  indicates 
the  formation  of  blood  channels  within  the  mass.  There  is  no 
continuance  of  blood  flow,  for  circulation  has  not  yet  been  estab- 
lished, but  minute  sinuses  have  been  formed,  and  they  are  filled 
with  sanguinary  fluid.  In  yet  another  day  or  two  these  will  have 
become  connected  with  the  blood  channels  of  the  surrounding 
tissues,  and  a  form  of  circulation  will  have  been  established.  The 
exudate  is  now  firmer,  and  cuts  like  new,  partially  formed  carti- 
laginous tissue.  The  mucous  membrane  and  epithelia  form  over 
it,  and  it  assumes  the  appearance  of  the  surrounding  gums.  Then 
commences  the  process  of  calcification,  and  soon  the  knife  feels 
the  grating  of  formative  bone.  Calcification  proceeds  until  the 
cavity  is  completely  filled  with  well-organized  bone  tissue.  This 
peculiar  form  of  healing  by  first  intention  will  not  be  observed 
except  in  cavities  that  are  well  protected  from  external  violence. 

If  this  kind  of  formative  tissue  in  its  early  periods  of  develop- 
ment is  examined  under  a  microscope,  it  will  be  found  filled  with 
small  round  cells,  which  gradually  assume  a  spindle  form,  and 
the  deepest  layer  will  be  found  composed  of  bundles  of  them. 
This  is  a  part  of  the  process  of  the  formation  of  embryonal  tissue, 
which  gradually  is  developed  into  that  of  a  more  perfect  type. 
The  cicatrix  is  connective  tissue  that  has  contracted  in  the  course 
of  its  formation,  and  which  thus  tends  to  draw  together  the  edges 
of  a  wound,  but  which  may  be  so  excessive  as  seriously  to  inter- 
fere with  function,  as  is  the  case  in  extensive  burns.  The  surgeon 
accomplishes  this  coaptation  of  the  borders  of  wounds  by  means 
of  sutures. 


THE    PRODUCTS    OF    INFLAMMATION.  43 

Third  Intention. — This  is  the  term  applied  to  the  process  of 
healing  zvhen  tzvo  granulating  superficies  come  or  are  brought 
into  coaptation.  It  does  not  essentially  differ  from  second  inten- 
tion, which,  indeed,  must  be  precedent  to  the  vmion  of  the  granulat- 
ing- surfaces. 

When  by  means  of  a  continuance  of  the  irritation  the  inflam- 
matory process  is  exacerbated,  or  when  new  sources  of  irritation 
are  introduced  and  infection  succeeds,  the  healing  process  is  inter- 
fered with,  and  the  plastic  exudate,  instead  of  being  organized  into 
tissue,  loses  its  integrity  and  is  broken  down,  involving  the  invest- 
ing tissue.  This  may  be  by  (1)  Suppuration,  (2)  Gangrene,  (3) 
Necrosis. 

Suppuration,  or  the  formation  of  pus,  is  molecular  degenera- 
tion through  septic  infection.  The  exudate,  from  continued  irrita- 
tion or  from  a  lack  of  nutrition,  loses  its  organizing  power,  becomes 
infected  by  pyogenic  micro-organisms,  degenerates,  and  forms  pus. 
The  leucocytes,  or  white  blood  corpuscles  that  have  migrated  to 
the  inflamed  territory,  die  and  become  the  characteristic  pus 
corpuscle.  The  plasma  melts  down  and  is  mingled  with  the 
extravasated  serum  of  the  blood.  The  tissue  in  the  immediate 
neighborhood  is  infected,  degenerates  and  breaks  down,  and  a  pus 
cavity  is  thus  formed. 

Pus,  then,  is  composed  of  (a)  the  pus  corpuscles  or  dead  leuco- 
cytes, (b)  the  melted  down  plasma  and  exuded  serum  from  the  blood, 
and  (c)  the  necrotic  or  decomposed  tissue  into  which  it  has  been 
infiltrated.  It  is  essentially  a  foreign  substance,  and  Nature  puts 
forth  her  utmost  efforts  to  expel  it  from  the  system.  The  pressure  is 
considerable,  and  the  tissue  in  the  line  of  least  resistance  yields  and 
becomes  disorganized  and  decomposed,  thus  extending  the  pus 
cavity,  usually  toward  the  periphery,  or  some  natural  cavity  of 
the  body.  This  continues  until  it  is  discharged  upon  the  surface 
and  an  abscess  is  formed.  The  determination  of  this  destructive 
process  toward  the  place  of  exit  is  called  the  "pointing"  of  the 
abscess. 

If  the  irritation  has  now  ceased,  as  in  the  case  of  the  extru- 
sion or  removal  of  some  foreign  substance  that  was  in  the  tissues, 
the  process  of  healing  commences,  and  may  proceed  by  granula- 
tion until  the  lesion  has  been  completely  restored.     If  the  irritant 


44  ORAL    PATHOLOGY    AND    TRACTICE. 

is  not  carried  away  by  the  first  suppuration  the  process  will  be 
repeated.  In  a  discharging  alveolar  abscess  arising  from  irritation 
and  infection  of  the  pericementum  of  a  dead  tooth,  the  plastic 
exudate  will  be  effused  about  the  point  of  irritation,  only  to  be 
infected  in  its  turn,  and  to  break  down  with  new  formation  of  pus. 
At  first  these  pointings  will  be  periodical.  They  may  be  precipi- 
tated by  any  general  inflammatory  condition,  and  follow  upon  the 
so-called  taking  of  a  cold.  After  a  time  the  condition  becomes 
chronic.  There  is  a  steady  effusion  of  the  exudate,  and  it  is  as 
regularly  infected  and  broken  down,  and  thus  an  almost  continuous 
discharge  of  pus  from  the  sinus  formed  is  the  result. 

Pus  was  formerly  classed  as  laudable  or  healthy,  serous, 
sanious,  ichorous,  etc.  We  now  know  that  the  thick,  creamy, 
opaque,  yellowish  discharge,  which  was  formerly  denominated 
laudable  pus,  is  the  uncontaminated,  undecomposed  discharge  from 
a  healthy  granulating  surface,  or  from  one  in  the  process  of  normal 
healing. 

Ichorous  pus  is  the  thin  and  acrid  ejection  from  an  ulcerative 
surface,  or  is  that  zvhich  has  passed  through  a  second  degenerative 
process.  It  may  be  excoriating  and  cause  an  abrasion  of  the  sur- 
rounding tissues  if  they  are  not  protected  from  its  influence. 

Sanious  pus  is  that  zvhich  is  mixed  ivith  blood,  and  zvhich  partakes 
of  the  nature  of  both.  It  is  usually  an  indication  of  a  destructive 
action,  and  of  the  cellular  sloughing  that  accompanies  the  breaking 
down  of  tissue.     It  may  be  ichorous  in  its  character. 

Serous  pus  is  that  zsohich  is  mixed  with  scrum  from  the  blood. 
It  differs  from  sanious  pus,  in  that  it  is  more  simple  in  its  nature, 
and  is  not  indicative  of  secondary  putrefactive  changes. 

Muco-pus  is  that  zvhich  is  mixed  zvith  the  secretions  of  the  mucous 
glands.  This  is  probably  but  an  accidental  complication,  and  the 
character  of  the  pus  is  not  thereby  materially  changed.  It  does  not 
imply  that  there  has  been  any  secondary  infection  with  destructive 
organisms,  or  any  putrefactive  degenerations. 

Gangrene  is  also  known  as  mortification,  and  when  sloughing 
takes  place,  as  sphacelus.  It  is  the  cessation  of  all  nutrition  in  a 
territory  more  or  less  considerable  and  circumscribed,  with  a  conse- 
quent loss  of  function  and  death  in  mass.  Its  origin  may  be  in  a 
traumatism  or  wound,  in  a  local  cause  like  thrombus  or  embolism, 
in  continued  pressure  either  external  or  internal,  in  the  too  free 


THE    PRODUCTS    OF    INFLAMMATION.  45 

use  of  certain  drugs,  such  as  ergot,  phosphorus,  mercury,  or 
carbohc  acid,  and  finally  in  constitutional  causes,  such  as  diabetes 
or  anemia.  It  is  usually  divided  into  moist  and  dry,  or  senile, 
gangrene.  When  the  degenerative  changes  which  succeed  loss 
of  nutrition  in  a  part  have  commenced,  there  may  be  an  infection 
with  certain  bacteria  of  decomposition,  and  the  whole  territory 
become  highly  septic.  The  tissue  is  in  a  putrefactive  state,  and 
auto-  or  self-inoculation  in  other  tissues  may  be  the  result.  This  is 
common,  or  moist  gangrene. 

In  addition  to  these  septic  conditions  of  gangrenous  degen- 
erations, the  disease  may  be  the  direct  result  of  infection.  There 
are  special  types,  due  to  the  activity  of  micro-organisms,  that  have 
long  been  distinguished  as  phlegmonous  erysipelas,  malignant 
edema,  hospital  gangrene,  noma,  etc.  Hospital  gangrene  is  now 
almost  unknown,  its  disappearance  as  a  separate  affection  being 
due  to  our  increased  knowledge  of  septic  conditions,  and  to  anti- 
septic precautions  and  treatment. 

Dry  or  senile  gangrene  presents  a  marked  difference  in  its 
objective  appearance  to  that  of  the  moist  type.  As  its  name  indi- 
cates, it  occurs  usually  in  old  people,  being  seldom  found  in  those 
under  fifty  years  of  age.  It  is  usually  caused  by  arterial  disease 
or  degeneration,  through  which  the  circulation  in  a  part  is  cut 
off.  The  tissue  being  deprived  of  blood,  the  moisture  is  lost  by 
evaporation,  and  there  is  a  consequent  shrinking  and  wrinkling 
of  the  tissues,  which  produces  that  peculiar  appearance  called 
mummification.  If  from  the  outset  putrefaction  is  prevented,  the 
type  of  gangrene  is  always  dry. 

This  affection  may  usually  be  readily  diagnosed.  The  pecu- 
liar appearance  of  the  tissues,  with  the  odor  of  putrefaction,  in 
moist  gangrene,  and  the  coldness,  dryness,  and  pallor  of  dry 
gangrene,  seldom  leave  the  surgeon  in  doubt  as  to  the  nature  of 
the  affection. 

Necrosis,  which  in  its  general  signification  means  the  death  of  a 
part,  may  be  properly  used  to  include  gangrene.  In  its  surgical 
employment  the  term  is  now  restricted  to  death  of  the  hard  or  bony 
tissue.  It  is  the  analogue  of  gangrene  in  soft  tissues,  and  it  has 
the  same  general  etiological  origin.  It  is  the  stoppage  of  the 
nutritive  currents,  with  the  consequent  death  of  the  part.  From 
the  nature  of  the  tissue  in  which  it  exists,  its  progress  is  nat- 


46  ORAL    PATHOLOGY   AND    PRACTICE. 

urally  slower  than  is  that  of  gangrene,  but  the  tendency  is  the 
same,  and  it  should  end  in  the  sloughing  away  of  the  dead  part 
from  the  living.  When  such  a  necrosed  portion  of  a  bone  is 
thus  separated,  it  is  called  the  sequestrum,  while  the  result  of  a 
successful  effort  of  nature  to  build  up  new  bone  in  its  place  is  called 
the  involucrum.  Of  all  the  bones  of  the  body  the  inferior  maxillary 
is  most  apt  to  take  upon  itself  necrosed  conditions.  This  is  partly 
because  it  is  more  subject  to  accidents  than  most  bones,  but  chiefly 
because  from  its  peculiar  connection  with  the  rest  of  the  body,  its 
great  mobility  and  the  constant  and  violent  uses  which  it  is  made 
to  subserve,  nutrition  is  the  more  readily  interfered  with.  About 
three  cases  of  necrosis  of  the  lower  jaw  occur  to  one  of  the  upper. 

It  will  be  seen,  from  a  retrospective  view  of  the  preceding 
statements  of  the  condition  called  inflammation,  that  it  is,  as  was 
affirmed  at  the  outset,  the  initial  point  of  very  many  changes  in 
the  body,  of  a  physiological  as  well  as  of  a  pathological  nature. 
It  commences  with  simple  hyperemia,  and  ends  with  the  final 
disposal  of  the  plastic  exudate  by  either  progressive  or  retro- 
gressive metamorphosis.  It  is  the  result  of  an  irritant,  which 
produces  a  more  or  less  profound  impression  upon  the  tissues 
through  the  nervous  shock.  The  vaso-motor  system  is  thereby  so 
disturbed  as  to  modify  the  conditions  of  the  bloodvessels  in  the 
neighborhood  of  any  lesion,  and  to  permit  the  passage  into  the 
tissues  of  their  contents,  through  diapedesis.  This  extra vasated 
matter  is  the  plastic  exudate  that  is  either  organized  or  disorgan- 
ized, and  it  is  the  result  of  the  earlier  stages  of  the  inflammatory 
process. 

The  termination  of  inflammation,  then,  is  either  in  the  build- 
ing up  of  the  plastic  exudate  into  new  tissue,  by  first  intention  or 
by  granulation,  or  in  its  degeneration  and  tearing  down  by  suppura- 
tion, gangrene,  or  necrosis.  The  final  result  depends  upon  the 
degree  of  the  lesion  or  injury,  upon  external  sanitary  or  unsanitary 
surroundings,  upon  constitutional  tonic  or  atonic  conditions,  and 
upon  the  ability  to  maintain  the  circulation  practically  unimpaired. 


GENERAL    TREATMENT   OF    INFLAMMATION.  47 

CHAPTER  X. 
GENERAL  TREATMENT  OF  INFLAMMATION'. 

The  treatment  of  inflammatory  states  will  necessarily  be 
largely  general  in  its  character.  The  various  remedies  to  be 
employed  may  be  classified  as  follows: 

For  the  heat — Reduce  the  temperature  by  refrigerants. 

For  the  swelling — Use  compression :  apply  bandages. 

For  the  hyperemia — Use  depletion :  leeches,  cupping,  etc. 

To  produce  metastasis — Counter-irritants,  blisters,  etc. 

To  relieve  circulation — Cathartics,  diaphoretics,  diuretics. 

To  equalise  the  circulation — Hot  pediluvia  (foot-baths). 

For  the  fever — Febrifuges,  antiphlogistics. 

For  the  pain — Sedatives,  anodynes,  local  anesthetics. 

To  promote  suppuration — Warmth,  moisture,  poultices. 

The  first  remedial  measure  to  be  employed  will  of  course  bs 
the  removal  of  the  cause  of  the  irritation,  provided  this  can  be 
definitely  ascertained.  The  next  will  be  to  give  rest  to  the  parts. 
The  latter  is  best  secured  by  immobility  and  entire  repose.  All 
.use  of  the  affected  organ  should  cease,  and  it  should  be  placed 
in  the  easiest  position  possible.  Saline  cathartics  may  be  adminis- 
tered, with  the  view  of  relieving  the  tension  of  the  bloodvessels 
by  a  depletion  of  their  watery  contents.  Diuretics  are  useful  for 
the  same  reason.  If  a  laxative  only  is  desired,  Seidlitz  powders 
may  be  prescribed,  or  mild  doses  of  castor  oil.  For  a  saline 
cathartic,  Epsom  or  Rochelle  salts  (magnesium  sulphate,  sodium 
tartrate),  or  cream  of  tartar  (potassium  bitartrate),  may  be 
employed.  But  still  more  efficacious  are  diaphoretic  remedies, 
because  they  not  only  remove  the  water  of  the  blood  and  tissues 
but  act  as  refrigerants,  through  evaporation  from  the  surface. 
They  also  tend  to  depuration  by  opening  the  pores  of  that  great 
eliminative  organ,  the  skin.  Dover's  powder,  or  some  form  of 
alcohol,  with  warmth  and  diluent  drinks,  may  be  used.  In  general 
forms  of  inflammation,  febrifuges,  such  as  potassium  chlorate, 
quinine,  antipyrine,  and  antifebrine,  should  be  administered,  and  the 
general  hygiene  should  be  carefully  looked  to.  If  there  is  general 
irritation,  sedatives,  either  arterial  or  nervous,  as  may  be  indicated, 
should  be  given. 


48  ORAL    PATHOLOGY   AND    PRACTICE. 

If  the  inflammation  shall  have  proceeded  to  the  point  of 
eifusion  of  its  products,  early  efforts  are  usually  directed  toward 
bringing  about  resolution,  or  absorption  of  the  lymph. 

Local  cupping  or  bleeding  may  be  useful,  although  the  best 
means  for  securing  local  depletion  will  usually  be  by  the  applica- 
tion of  leeches.  These  agents,  which  have  of  late  been  almost 
entirely  abandoned,  will  often  prove  of  greatest  efficacy.  In  addi- 
tion to  the  general  remedies  recommended,  counter-irritants  may 
be  employed.  These  induce  a  change  in  the  location  of  the 
inflammation  by  metastasis,  or  the  production  of  a  new  point  of 
irritation,  with  the  consequent  transference  of  the  seat  of  diseased 
action. 

Park  recommends,  in  forms  of  phlegmonous  infiltration,  the 
application  of  an  ointment  composed  of  resorcin  5,  ichthyol  10, 
mercurial  ointment  3,  and  lanolin  50  parts,  as  a  sorbefacient  and 
antiseptic  preparation.  This  in  connection  with  moist  heat  may 
even  secure  the  actual  resorption  of  pus. 

If  there  is  local   swelling,   it   may   sometimes  be   controlled 
by  bandaging,  which  prevents  further  efTusion  and  promotes  the 
absorption   of  that   which   has   already  taken   place.     It   is   not, 
however,  usually  convenient  to  apply  a  bandage  or  exert  much  . 
pressure  upon  any  of  the  oral  tissues. 

If  there  is  considerable  local  heat,  it  may  be  controlled  by 
the  application  of  ice,  or  by  the  ether  or  alcoholic  spra3^ 

If  neither  resolution  nor  building  up  of  tissue  seems  possible 
or  probable,  efforts  should  be  directed  toward  the  promotion  of 
suppuration,  thus  relieving  the  tissues  of  the  products  of  the 
inflammatory  process.  It  is  here  that  the  oral  physician  or  sur- 
geon will  have  an  opportunity  for  the  exercise  of  his  best  judg- 
ment, and  all  his  experience  will  be  needed  in  making  his  prog- 
nosis, to  determine  the  exact  point  at  which  the  treatment  should 
be  changed.  To  ascertain  when  the  degenerative  process  has 
begun  requires  the  nicest  perception  and  discernment.  In 
inflammation  of  the  dental  pulp,  for  instance,  to  know  when  it 
is  no  longer  wise  to  attempt  to  preserve  its  vitality,  and  when 
devitalization  and  extirpation  are  advisable  in  view  of  positive 
degenerative  changes  that  are  imminent,  requires  a  thorough 
knowledge,  not  only  of  the  whole  inflammatory  process,  but  of 
the  symptomatography  of  all  the  lesions  and  complications  as  well. 


GENERAL    TREATMENT    OF    INFLAMMATION.  49 

The  breaking  down  of  tissue  having  already  commenced,  or 
being  plainly  inevitable,  suppuration  should  be  hastened,  that  the 
more  destructive  processes  of  gangrene  and  necrosis  may  not 
supersede  it.  Poultices  should  at  once  be  employed  in  the  direc- 
tion in  which  it  is  desired  that  the  abscess  shall  break.  This 
promotes  suppuration  by  extending  such  favorable  conditions,  as 
are  afforded  by  a  maintenance  of  the  temperature,  the  continued 
presence  of  moisture  for  the  softening  of  the  tissues,  and  the  dila- 
tation of  the  vessels.  Any  poultice  that  will  secure  this  will  suffice, 
although  if  it  is  of  a  fermentative  substance,  that  process  will  assist 
in  the  weakening  of  the  superincumbent  tissues. 

It  is  not  convenient  to  use  for  oral  application  the  poultices 
commonly  employed  in  general  medicine.  A  freshly  cut  fig  or 
a  split  raisin  may  often  be  applied  when  no  other  can,  and  they 
act  very  efifectually.  They  should  usually  be  softened  and  warmed 
by  dipping  in  hot  water.  They  are  pleasant  to  use  in  the  mouth, 
and  when  one  piece  becomes  too  much  softened  another  is  readily 
substituted.  They  will  usually  be  held  in  place  by  the  facial 
muscles. 

There  are  certain  general  remedies  that  promote  suppuration 
under  definite  conditions,  but  they  are  little  adapted  to  oral  prac- 
tice. In  the  treatment  of  inflammation  the  aim  should  always  be, 
after  diapedesis  has  taken  place,  to  relieve  the  tissues  of  the  exu- 
date material,  and  to  promote  healing  when  there  has  been  any 
traumatic  wound  or  lesion. 

Whenever  pus  is  present  it  must  be  promptly  evacuated. 
It  is  always  irritative,  always  degenerative  in  its  influence. 
There  is  no  precept  in  practice  that  is  so  imperative  as  the  one 
which  instructs  the  practitioner  at  once  to  get  rid  of  pus.  There 
is  no  surgical  risk  that  one  is  not  justified  in  taking  if  this  product 
can  be  eliminated  in  no  other  way.  Sometimes  a  mere  puncture  will 
evacuate  it,  at  other  times  a  serious  operation  is  demanded;  but, 
whether  simple  or  complicated  the  means  of  elimination,  it  must 
not  be  permitted  to  remain.  Some  judgment  may  be  required  in 
securing  perfect  drainage  if  an  opening  is  made,  and  this  demands 
that  the  artificial  sinus  shall  be  at  the  lowest,  most  dependent  point 
when  the  body  is  in  its  natural  position.  Drainage  tubes  may  be 
demanded;  or  gauze,  catgut  strands,  or  other  media  may  be  used 
to  keep  the  opening  patulous.  These  may  be  retained  in  position 
by  strips  of  adhesive  plaster. 

5 


50  ORAL    tATHOLOGY   AND    PRACTICE. 

After  evacuation  the  pus  cavity  should  be  cleansed  and  disin- 
fected with  hydrogen  dioxide,  pyrozone,  or  some  other  effective 
antiseptic  or  disinfectant  solution.  The  utmost  care  should  after- 
ward be  exerted  to  keep  the  cavity  clean  and  aseptic,  if  proper  heal- 
ing after  the  discharge  of  the  broken-down  infiltrate  is  to  be 
secured. 


CHAPTER  XI. 
DISEASES  OF  THE  GUMS. 


The  gums  are  largely  made  up  of  fibrous  tissue  covered  by 
mucous  membrane.  In  their  normal  condition  they  are  of  a  deli- 
cate pink  color,  and  are  dense  and  hard.  They  invest  the  teeth 
closely,  and  are  adherent  at  their  cervical  portion.  They  are  not 
especially  sensitive,  and  in  the  absence  of  the  teeth  most  kinds  of 
food  may  be  crushed  upon  them  without  great  discomfort.  Any 
departure  from  this  general  appearance  or  state  is  a  pathological 
condition  that  demands  attention  from  the  dentist  or  oral  physi- 
cian. Local  irritations,  inflammations  and  hypertrophies,  or  hyper- 
plastic conditions  of  the  gum  tissues  are,  however,  too  seldom 
recognized,  or  if  noticed  are  not  accorded  proper  treatment.  That 
which  should  form  a  considerable  proportion  of  the  practice  of 
every  dentist  is  sadly  neglected. 

Especially  has  this  been  the  case  in  the  past.  Formerly  the 
college  terms  were  sO'  short  that  it  was  absolutely  impossible  to 
give  adequate  instruction  in  very  many  pathological  conditions. 
Of  late  the  curriculum  has  been  materially  broadened,  and  students 
have  impressed  upon  them  the  overwhelming  importance  of  prophy- 
lactic treatment  and  the  early  employment  of  remedial  measures  for 
the  cure  of  oral  disorders,  before  they  shall  have  wrought  irrepar- 
able mischief. 

Inflamed,  irritable,  turgid  gingivae,  loosened  from  their 
attachment  to  the  teeth  so  that  the  point  of  an  explorer  can  pene- 
trate some  distance  beneath  their  free  margins  without  resistance, 
with  degenerated,  atonic,  congested  bloodvessels  that  discharge 
their  contents  at  the  least  irritation,  are  even  now  so  common  as  to 
excite  little  comment,  and  the  patient  is  dismissed  without  the 


DISEASES    OF   THE    GUMS.  5I 

proper  professional  advice  or  remedial  attention.  (See  Fig.  13.) 
These  same  unfaithful  practitioners  perhaps  bewail  the  multiplica- 
tion of  dentists,  and  insist  that  our  schools  should  limit  the  launch- 
ing of  new  graduates  upon  an  already  crowded  profession,  because 
there  is  not  enough  of  practice  for  those  already  in,  while  them- 
selves neglecting  a  large  proportion  of  the  field  that  should  be 
covered.  Properly  to  care  for  the  disregarded  conditions  of  the 
mouths  of  the  people  of  this  country  would  far  more  than  employ 
the  time  of  all  the  dentists  now  in  practice.  The  proper  remedy  for 
a  stream  that  overflows  its  banks  is  to  widen  and  deepen  its  channel, 
instead  of  attempting  to  dry  up  its  waters,  and  there  are  unoccupied 
fields  within  the  province  of  dentistry  not  only  as  yet  uncultivated 
but  almost  unexplored. 

Local  irritation  is  the  cause  of  most  of  the  inflammations  and 
hypertrophies  of  the  gums  that  are  so  commonly  met  with.     Usually 

Fig.  13. 


Gingival  Hypertrophy  and  Turgescence,  the  Result  of  Neglect. 

this  is  due  to  lack  of  care  on  the  part  of  the  patient.  Foreign  mat- 
ter is  deposited  at  the  cervical  portions  of  the  teeth,  and  this  by  its 
excitant  action  stimulates  the  tissues  to  abnormal  activity.  The 
consequence  is  an  overgrowth,  an  hypertrophy  or  hyperplasia  of 
tissue.  This  may  be  confined  to  a  single  tooth,  or  it  may  be  more 
widely  diffused  and  involve  nearly  or  quite  the  whole  of  the  denti- 
tion. The  tumefaction  will  be  especially  pronounced  in  the  gum 
covering  the  septum  between  the  teeth,  where  the  irritation  is 
greatest.  If  there  are  carious  cavities,  not  infrequently  they  will  be 
completely  filled  with  hyperplastic  tissue,  connected  with  the  rest 
by  a  slender  pedicle.  The  margins  of  the  gums  will  be  thick, 
everted,  and  of  a  deep  red  color,  almost  approaching  a  purple. 
There  may  be  a  breaking  down  of  the  tissue  with  pus  formation, 
entirely  distinct  from  that  condition  called  pyorrhea.  The  mucous 
follicles  of  the  gums  are  in  a  degenerative  state,  and  their  secretion 


52  ORAL    PATHOLOGY    AND    PRACTICE. 

no  longer  properly  lubricates  the  tissues,  but  adds  to  the  disturb- 
ance by  its  perverted  character. 

These  conditions  arise  as  the  effect  of  lack  of  care,  local  irri- 
tation due  to  the  presence  of  foreign  substances,  rough  projecting 
fillings,  or  deposits  about  the  necks  of  the  teeth.  Diagnosis  is  not 
difficult,  for  the  very  existence  of  the  disturbance  indicates  the 
presence  of  exciting  agents.  The  first  curative  measures  to  be 
adopted  obviously  is  the  removal  of  any  local  deposits  or  foreign 
substances.  Nor  is  it  sufficient  to  do  this  superficially.  Wherever 
there  is  any  undue  amount  of  tissue  or  tumefaction,  beneath  it, 
perhaps  at  the  very  edge  of  the  alveolar  walls,  will  be  found  some- 
thing foreign.  It  is  absolutely  essential  that  the  instrument  used 
should  penetrate  to  the  point  of  attachment  beneath  the  inflamed 
tissue,  and  to  this  end  one  that  has  a  chisel  edge,  adapted  to  a 
pushing  motion,  will  be  most  efifectual,  for  anything  thicker  will 
not  reach  to  the  very  extremity.  It  should  not  be  forgotten  that 
the  most  mischievous  irritant  matter  is  that  which  lies  deepest, 
and  nearest  the  point  of  actual  attachment  of  the  pericementum  to 
the  tooth. 

Minute  spicules  of  calcific  matter  are  those  which  cause  the 
greatest  disturbance.  Whether  these  have  their  origin  in  the  fluids 
of  the  mouth  or  of  the  circulatory  system,  whether  they  are  salivary 
or  sanguinary,  local  or  constitutional,  their  operative  treatment  is 
the  same.  That  such  deposits  of  hard,  sharp,  segregated  granules 
beneath  the  gums  differ  from  the  ordinary  tartar  or  salivary  calculus 
that  is  precipitated  upon  the  supra-gingival  portions  of  the  teeth 
must  be  patent  to  everyone,  but  whether  this  divergence  is  due  to 
its  derivation,  or  merely  to  the  manner  and  place  of  its  deposit,  we 
need  not  now  inquire.  Certain  it  is  that  its  removal  is  more  diffi- 
cult than  that  of  ordinar}^  salivary  calculus.  It  perhaps  will  not  be 
detected  without  the  exercise  of  considerable  care,  for  it  sometimes 
exists  in  minute  granules  that  would  be  invisible  even  if  not  covered 
by  the  inflamed  gum. 

A  solution  of  trichloracetic  acid,  of  from  twenty  to  fifty  per 
cent,  will  greatly  aid  in  the  removal  of  these  deposits.  It  may  be 
carried  on  the  edge  of  a  sharp,  wedge-shaped  piece  of  orange  wood 
that  has  been  dipped  in  the  solution,  or  a  small  rope  of  cotton  may 
be  saturated  and  with  an  excavator  carefully  carried  up  to  the  very 
point  of  attachment  of  gum  and  tooth,  and  there  allowed  to  remain 


DISEASES    OF    THE    GUMS.  53 

for  a  few  moments.  While  the  acid  does  not  remove  the  deposits 
by  dissolving  them,  it  will  loosen  their  attachment  to  the  teeth, 
and  soften  them  enough  to  facilitate  their  removal  with  the  scaler. 
At  the  same  time  the  remedy  acts  as  a  slight  cauterant,  inducing  a 
slough  of  the  superficial  parts  of  the  degenerative  tissue,  and  reduc- 
tion of  the  inflammatory  condition  by  its  astringent  and  alterative 
action  upon  the  distended,  congested  capillaries.  A  solution  of 
lactic  acid  has  been  highly  recommended  for  the  same  purpose. 
The  patient  should  be  directed  to  use  frequent  massage  of  the 
gums  with  the  ball  of  the  finger,  and  the  persistent  use  of  a  soft 
tooth-brush  should  be  insisted  upon.  The  mouth  should  be  gargled 
and  the  gums  washed  with  a  solution  of  ten  grains  of  chlorate  of 
potash  to  the  ounce  of  water,  and  if  necessary  a  solution  of  chloride 
of  zinc  may  be  prescribed  for  oral  use.  If  there  is  a  great  deal  of 
bleeding,  tannic  acid  may  be  rubbed  upon  the  gums  with  the  finger. 
If,  as  is  probable,  an  antiseptic  wash  is  needed,  a  solution  of  boro- 
glycerol  in  water,  one  part  to  ten,  may  be  used  as  a  wash  or  with 
the  brush.  It  will  not  usually  be  wise  to  attempt  the  removal  of  the 
deposits  from  all  the  teeth  at  one  time,  if  many  are  affected. 

The  medicinal  treatment  needs  repeating  at  intervals  of  a  few 
days  until  the  condition  is  changed,  and  it  is  well  at  each  of  the 
visits  to  explore  still  further  for  irritating  substances.  An  indica- 
tion of  their  existence  and  their  locality  will  be  found  in  the  local 
persistence  of  the  inflammation.  Any  red,  irritable  point  of  hyper- 
frophied  gum  will  usually  be  found  to  cover  the  cause  of  irritation. 

Of  the  inflammations  arising  from  loose  or  ragged  teeth  it  is 
unnecessary  to  speak.  The  removal  of  the  source  of  irritation 
will  be  sufficient.  The  gums  beneath  ill-fitting  plates  frequently 
become  tumefied,  and  sometimes  sloughing  ensues.  This  is 
especially  the  case  with  rubber  plates,  not  because  they  generate 
any  heat,  but  because  they  are  non-conductors  and  the  tissue 
beneath  them  is  not  subjected  to  the  same  variations  of  tempera- 
ture as  the  other  and  surrounding  tissues.  The  condition  may 
sometimes  be  found  beneath  metal  plates  that  are  not  adapted  to 
the  mouth,  if  they  are  worn  continuously,  but  there  is  not  the 
same  degenerative  lack  of  tone  in  the  bloodvessels  that  is  found 
beneath  rubber  dentures.  The  congestion  is  usually  less  intense, 
and  sloughing  is  more  infrequent.  The  cure  for  this  condition  will 
be  found  in  the  construction  of  a  proper  denture,  and  its  inter- 


54  ORAL    PATHOLOGY   AND   PRACTICE. 

rupted  use.  No  artificial  plate  should  be  allowed  to  remain  in  the 
mouth  over  night.  The  tissues  should  be  given  that  opportunity 
for  rest  and  the  recovery  of  their  normal  tone. 


CHAPTER  XII. 
STOMATITIS. 


The  word  is  derived  from  the  Greek  "stoma,"  a  mouth,  and  the 
termination  "itis,"  inflammation,  so  that  it  implies  an  inflamma- 
tory condition  of  the  tissues  of  the  mouth.  The  term  is  a  very 
broad  one,  and  may  be  made  to  cover  very  diverse  conditions.  Its 
application,  however,  is  usually  restricted  to  the  mucous  mem- 
brane and  the  soft  tissues  in  immediate  relation  with  it.  It  is  very 
common  in  infants,  among  the  lower  classes  of  foreigners  espe- 
cially, and  is  usually  due  to  bad  hygiene  or  unsanitary  conditions. 
Especially  is  this  the  case  with  those  that  are  artificially  fed  instead 
of  being  nursed  by  the  mother.  Either  the  food  is  of  an  improper 
character,  or  the  nursing-bottle  is  not  often  enough  scalded  or 
boiled  out  to  prevent  the  growth  of  fermentative  organisms,  and 
the  milk  used  is  thus  infected.  The  rubber  nipple  and  tube  are 
often  the  source  of  irritation  to  the  oral  tissues.  The  rubber  under 
the  influence  of  light  and  heat  rapidly  commences  decomposition, 
and. thus  becomes  the  means  of  poisoning  the  mouth;  or  it  may 
harbor  destructive  fungi,  and  these  are  especially  irritating  to  the 
mucous  membrane. 

Follicular  Stomatitis,  the  simplest  form,  is  an  inflammation  of  the 
mouths  of  the  mucous  follicles.  It  is  either  accompanied  by  or  will 
bring  about  degenerative  changes  of  the  mucosa  itself,  and  this 
may  add  materially  to  the  irritation.  Perhaps  but  a  portion  of  the 
surface  may  be  affected,  and  the  membrane  presents  a  punctate 
appearance — flecked  over  with  red  points.  With  the  increase  of 
the  inflammatory  condition  more  of  the  follicles  are  involved,  until 
the  patches  become  confluent,  and  the  whole  surface  is  tumid  and 
turgid.  In  this  condition  the  tissues  of  the  mouth  look  hot,  dry, 
and  red.  The  mouth  becomes  sensitive,  and  the  child  shrinks 
from  its  examination.     There  will,  in  the  earlier  stages,  be  an 


STOMATITIS.  55 

excessive  slavering,  or  flow  of  watery  saliva.  There  will  be  more 
or  less  of  febrile  disturbance,  and  the  bowels  will  probably  be 
irregular,  a  constipated  condition  predominating.  During  a  later 
stage  the  secretions  of  the  follicles  become  yet  more  depraved 
and  no  longer  give  the  normal  lubrication  to  the  parts.  The  de- 
generation spreads  to  the  connective  tissue,  the  mouth  becomes 
dry  and  parched,  the  bloodvessels  are  congested  and  active  nutri- 
tion is  interrupted,  the  congestion  reaches  the  point  of  stasis,  or 
stoppage  of  the  circulation,  and  sloughing  commences. 

Acute  Stomatitis  may  be  induced  by  improper  feeding,  aside 
from  unsanitary  conditions.  The  infant  that  is  fed  with  a  food 
that  it  cannot  digest  will  be  poorly  nourished,  and  all  kinds  of 
degenerations  may  be  established.  The  irritative  condition  of  the 
digestive  tract  may  produce  diarrhea  and  gastric  disturbances 
which  by  mere  continuity  of  tissue  may  extend  to  the  oral  mucous 
membrane,  and  an  ulcerative  stomatitis  may  be  established  as  the 
result  of  the  atonic,  innutritive  state,  and  the  spread  of  the  inflam- 
mation from  the  irritated  digestive  tract. 

Ulcerative  Stomatitis  is  merely  an  advanced  stage  of  the  first 
condition.  The  mucous  follicles  become  so  degenerated  that  their 
functions  quite  cease,  and  cracks  and  fissures  open  in  the  unlubri- 
cated  tissues.  All  the  preceding  symptoms  are  aggravated.  The 
child  cannot  without  great  difficulty  take  its  food,  and  w'hat  is 
ingested  afifords  little  nutriment,  because  of  the  gastric  disturb- 
ances that  are  always  present.  There  is  a  constant  swallowing  of 
ofifensive  matter  from  the  mouth,  with  a  wasting  diarrhea  or  dysen- 
tery. 

Abovit  this  time  the  submucous  tissue  will  perhaps  become 
thickened  and  indurated  in  spots.  Sometimes  there  will  be  ptyal- 
ism,  with  a  great  flow  of  watery  saliva  succeeding  the  dried  condi- 
tion of  the  oral  cavity.  The  submaxillary  gland  may  become  ten- 
der and  tumid.  Small  vesicles  may  appear  in  the  mouth,  seem- 
ingly filled  with  a  watery  serum.  These  burst  and  form  an  ulcer, 
with  a  dirty-white  slough.  The  child  becomes  greatly  emaciated, 
and  there  is  excessive  swelling  of  the  oral  tissues.  The  breath 
becomes  very  offensive,  and  the  ulcers  show  a  considerable  slough- 
ing. Unless  speedy  relief  is  obtained,  the  child  will  soon  succumb 
through  lack  of  nutrition,  as  well  as  to  the  infectious  products  of 
the  septic  condition.  • 


56  ORAL    PATHOLOGY    AND    PRACTICE. 

Aphthous  Stomatitis  is  a  form  that  may  attack  people  of  almost 
any  age,  and  is  characterized  by  some  special  appearances.  Small 
round  or  oval  ulcers  appear  upon  the  reddened  mucous  membrane 
of  the  lips,  cheeks,  tongue,  or  gums.  They  are  from  one  to  three 
lines  in  diameter,  very  little  depressed,  with  a  yellowish  or  white 
floor,  and  a  red,  narrow,  perhaps  slightly  indurated,  border. 
Sometimes  two  or  more  of  them  become  confluent,  thus  forming 
an  irregular,  large  ulcer.  When  these  heal  they  leave  no  cicatrix. 
The  aphthse  do  not  spread  like  the  spots  in  ulcerative  stomatitis,  and 
they  are  distinctly  painful,  while  the  ulcers  are  not. 

Usually  there  is  an  increased  flow  of  saliva  accompanying 
them,  the  mouth  is  hot  and  feverish  and  the  tongue  heavily  coated. 
Sometimes  the  saliva  excoriates  the  skin  and  the  lips  are  thus  kept 
constantly  sore. 

Thrush  is  a  form  of  stomatitis  occurring  in  children  and  de- 
pendent upon  the  groivth  of  a  parasitic  fungus.  This  consists  of 
long,  jointed  threads,  the  O'idium  albicans,  which  seems  to  belong  to 
the  family  of  the  molds.  Thrush  appears  to  be  contagious.  On 
looking  into  the  mouth  of  young  infants  a  layer  of  thin  white  mem- 
brane may  perhaps  be  seen  covering  the  palatal  arch  and  appearing 
as  white  spots  upon  the  tongue,  while  the  mucous  membrane  about 
or  at  the  borders  of  this  coating  seems  to  be  in  a  healthy  condition. 

Thrush  in  children  is  apt  to  be  a  sequela  of  chronic  diarrhea, 
prolonged  starvation,  exhausting  fevers,  or  any  severe  and  debili- 
tating illness.  It  is  indicative  of  and  usually  accompanies  a  low, 
atonic  condition,  and  its  cure  will  depend  more  upon  feeding  than 
medicines,  first  allaying  any  gastric  or  intestinal  irritation. 

Noma,  Gangrenous  Stomatitis,  or  Cancrum  Oris,  is  a  kind  of 
vdcerative  stomatitis,  but  as  the  term  is  usually  employed  it  implies 
a  specially  vicious  degenerative  condifion,  due  to  infection  by  a  peculiar 
bacillus. 

The  preceding  remarks  are  more  especially  applicable  to  in- 
fantile stomatitis.  The  same  or  analogous  conditions  may  be 
induced  in  adults  by  like  causes.  Anemic  and  poorly  nourished 
persons  are  especially  liable  to  inflammations  of  the  oral  tissues. 
The  lips  are  dry  and  parched,  and  superficial  fissures  and  cracks  in 
the  mucous  membrane  appear.  In  a  less  degree  this  will  be  ob- 
servable upon  the  tongue,  the  buccal  surfaces,  and  in  the  vault  of 


TREATMENT    OF    STOMATITIS.  57 

the  mouth.  This  may  continue  for  some  time,  until  finally,  with  the 
progression  of  a  general  febrile  state,  a  more  active  stomatitis  is 
developed  that  may  result  in  a  local  breaking  down  or  ulceration. 

Neglect  of  the  teeth  and  the  mouth  tissues  is  a  fruitful  source 
of  stomatitis  in  adults.  Food  is  left  to  ferment  and  putrefy,  and 
the  products  of  this  action  will  be  exceedingly  irritative  to  the 
soft  tissues,  as  well  as  destructive  to  the  hard.  There  will  always 
be  gingivitis  present  in  the  mouths  of  those  who  do  not  give 
proper  attention  to  the  removal  of  foreign  substances  from  about 
the  teeth,  and  this,  by  continuity  of  tissue,  may  spread  all  over  the 
mouth.  Usually  the  action  of  the  saliva  upon  the  portions  freely 
washed  by  it  is  sufficient  to  keep  them  clean  and  normal.  But 
between  and  about  the  teeth,  where  food  remains  for  an  indefinite 
time,  in  the  absence  of  proper  care  the  gums  are  always  irritated 
and  more  or  less  congested,  and  this  may  spread  to  adjoining 
tissue,  with  the  result  of  an  acute  stomatitis  in  atonic  conditions. 


CHAPTER  XIII. 

TREATMENT  OF  STOMATITIS. 

In  infantile  affections  the  very  first  measures  to  be  adopted 
necessarily  imply  an  inquiry  into  the  food  and  feeding.     If  the 

child  is  artificially  fed,  the  nursing-bottle  should  be  carefully 
inspected,  and  the  food  that  is  given  must  be  scrutinized.  If  there 
is  anything  unsanitary  about  either,  it  must  be  at  once  corrected. 
The  rubber  nipple  and  tube  must  be  sterilized,  or,  what  is  better, 
discarded  and  substituted  by  a  new  one  that  has  been  made  thor- 
oughly aseptic.  If  the  child  is  poorly  nourished  through  improper 
or  insufficient  food,  that  must  be  remedied,  and  plenty  of  nutritious 
matter  that  can  be  readily  digested  and  assimilated  should  be 
given.  If  there  are  diarrheas  or  other  wasting  disorders,  which 
will  too  often  be  the  case,  they  must  at  once  be  attended  to;  it 
will  be  impossible  to  build  up  a  patient  while  any  process  of  waste 
is  going  on.  All  unhygienic  surroundings  must  be  remedied,  and 
the  patient  should  be  given  plenty  of  light  and  air,  and  proper 
exercise.     In  short,  beneficent  Mother  Nature,  upon  vvhom  we 


58  ORAL    PATHOLOGY   AND   PRACTICE. 

must  finally  rely  for  a  cure,  must  be  afforded  every  opportunity. 
Functional  activity  must  be  promoted,  and  all  obstacles  removed. 

After  securing  perfect  sanitation  the  local  treatment  will  be 
mainly  depurative  and  stimulative.  If  a  cathartic  is  indicated, 
two  drams  of  castor  oil  may  be  administered.  For  the  local 
irritation,  a  mouth-wash  consisting  of  a  solution  of  five  to  ten 
grains  of  chlorate  of  potash  to  the  ounce  of  water  may  be  used  as 
a  gargle.  If  the  child  is  too  young  to  use  this  itself,  a  swab  may 
be  made  by  tying  soft  linen  to  a  stick  of  proper  dimensions,  and 
this  may  be  used  to  apply  the  solution,  employing  a  proper  degree 
of  friction.  If  the  mouth  is  sore,  it  may  be  applied  with  a  soft 
brush.  The  mouth  may  be  occasionally  washed  out  with  the 
following  preparation,  especially  after  eating: 

IJ — Borax,  30  grains; 

Sodium  bicarbonate,  i  dram; 

Distilled  water,  4  ounces. 

Or  the  following  may  be  substituted  in  its  place : 

IJ — Boric  acid, 

Potassium  chlorate,  of  each  15  grains; 

Lemon  juice,  3^  ounce; 

Glycerol,  6  drams. 

If  an  antiseptic  is  needed,  a  solution  of  listerine,  one  part  in 
ten  parts  of  water,  may  be  used  in  the  same  way,  or  it  may  be 
administered  internally  when  diluted  with  simple  syrup.  Or  the 
following  may  be  prescribed: 

IJ — Listerine  (Lambert's),  2  ounces; 

Glycerol,  i  dram; 

Water,  to  make  4  ounces. 

Sig. — A  teaspoonful  after  nursing  or  feeding. 

If  there  are  cracks  in  the  tongue  or  fissures  in  the  cheeks,  a 
solution  of  borax  and  honey,  made  by  adding  one  dram  of  borax 
to  each  ounce  of  clarified  honey,  may  be  applied  locally. 

If  there  are  deep  erosions  of  the  mucous  membrane,  or  ulcera- 
tive surfaces,  it  may  be  necessary  to  cauterize  them,  either  with 
silver  nitrate,  pure  carbolic  acid,  or  chromic  acid  crystals.  The 
last  named  are  preferable  in  instances  in  which  they  can  be  con- 
veniently used.  The  cauterized  places  should  be  subsequently 
dressed  with  a  solution  of  calendula. 

The  treatment  of  follicular,  or  ulcerative,  stomatitis  in  adults 


TREATMENT    OF    STOMATITIS.  59 

does  not  materially  differ  from  that  in  infants,  except  that  more 
active  measures  may  be  used.  The  remedies  may  be  proportionately 
increased  in  strength,  and  personal  care  insisted  upon.  The  teeth 
should  be  thoroughly  cleaned,  and  all  broken  or  sharp  edges  re- 
moved. A  soft  tooth-brush  should  be  employed  after  every  meal, 
and  with  it  should  be  prescribed  some  antiseptic  wash.  A  two  per 
cent,  solution  of  zinc  chloride  may  be  used  as  a  gargle.  At  night  a 
spoonful  of  Phillips'  milk  of  magnesia  should  be  taken  into  the 
mouth  and  rinsed  about  all  the  teeth,  to  be  left  upon  them  until  the 
morning.  Enough  of  good  nourishing  food  should  be  given,  and 
the  patient  should  have  plenty  of  pure  air  and  sunshine. 

There  is  a  form  of  ulcer  that  is  the  result  of  the  careless  appli- 
cation of  arsenous  acid  in  the  devitalization  of  teeth,  which  may 
be  referred  to  in  this  connection.  Arsenic  is  a  corrosive  poison. 
It  produces  its  characteristic  effects  in  destroying  the  pulps  of 
teeth  through  its  corrosive  action,  and  not  through  congestion  and 
the  production  of  consequent  stasis  at  the  apical  foramen,  because 
it  will  promptly  kill  the  pulp  of  a  partially  developed  tooth  in  which 
the  root  is  entirely  open,  no  foraminal  constriction  having  yet  been 
formed,  and  in  which  strangulation  is  therefore  impossible.  When 
arsenous  acid  is  insecurely  sealed  up  in  the  cavity  of  a  tooth,  such  a 
defective  agent  as  cotton  wet  with  a  solution  of  gum  sandarac  being 
employed  for  that  purpose,  it  may  come  in  contact  with  the  buccal 
tissue  and  devitalize  that  as  it  does  the  pulp,  gradually  eating  its 
way  in  until  a  considerable  slough  is  produced. 

When  this  is  the  case,  the  ulcer  should  be  thoroughly  satu- 
rated with  dialyzed  iron,  to  limit  the  action  of  the  arsenic.  It 
should  then  be  dressed  with  a  solution  of  calendula,  and  kept  clean 
and  aseptic  until  it  has  healed.  Should  the  corrosive  effects  be 
manifest  between  the  teeth  and  reach  to  the  alveolar  bone,  it  will 
probably  induce  an  osteitis  that  may  end  in  caries  or  necrosis. 
When  this  is  the  case  the  affected  bone  should  be  promptly  burred 
away  before  using  the  dialyzed  iron. 

In  Gangrene,  or  Noma,  or  Cancrum  Oris,  thorough  cauteriza- 
tion or  removal  of  the  affected  tissue  will  probably  be  necessary, 
and  the  strictest  antiseptic  precautions  must  be  employed.  For  the 
general  symptoms  constitutional  treatment  must  be  taken.  Tonics 
should  be  employed,  with  fresh  air  and  a  sufficient  amount  of 
exercise.     Every  possible  effort  should  be  made  to  promote  nutri- 


60  ORAL    PATHOLOGY    AND    PRACTICE. 

tion,  and  especially  that  of  the  locally  affected  tissues.  In  fact, 
when  stomatitis  reaches  the  point  of  deep  ulceration  or  extensive 
breaking  down  of  tissue,  it  is  such  a  grave  condition  that  general 
constitutional  treatment  should  not  be  delayed. 

Sometimes  the  pulps  of  teeth  assume  a  gangrenous  condition. 
When  this  is  the  case,  there  is  great  danger  that  septicemia  and 
pyemia  may  be  the  consequence.  Miller  details  a  number  of  cases 
within  the  sphere  of  his  own  observation,  in  which  death  within 
a  very  few  days  has  been  the  result  of  the  gangrenous  infection 
of  a  tooth  pulp.  When  the  symptoms  of  general  septic  poisoning 
are  manifest,  no  time  should  be  lost  in  the  institution  of  the  proper 
general  remedial  measures,  the  consideration  of  which  is  beyond 
the  scope  of  this  work. 

In  cases  of  thrush  in  infants  that  are  badly  or  insufficiently 
nourished,  there  is  usually  more  or  less  of  gastric  or  intestinal  irri- 
tation in  connection  with  the  markedly  atonic  condition.  This  will 
probably  require  the  administration  of  such  correctives  as  rhubarb 
and  soda,  lime-water,  and  vegetable  bitters.  When  the  aphthae 
occur  in  older  persons  they  are  often  spoken  of  as  "canker  spots," 
or  "canker  sore  mouth."  The  usual  treatment  is  roughly  to  cau- 
terize the  spots  and  dress  them  with  a  solution  of  calendula.  If 
an  active  cauterant  is  not  desirable,  as  in  children,  the  aphthous 
patches  may  be  repeatedly  touched  with  the  following  solution: 

5 — Sodium  salicylate,  i  dram; 

Distilled  water,  6  drams. 

Or  in  place  of  the  preceding  this  may  be  used: 

5 — Borax,  45  grains; 

Sodium  salicylate,  75      " 

Tinct.  myrrh,  i  dram; 

Simple  syrup, 
Distilled  water,         of  each  Y^  ounce. 

If  the  aphthae  exist  in  considerable  numbers,  they  may  demand 
the  use  of  antiseptic  mouth-washes.  If  they  are  the  consequence 
of  a  general  anemic  condition,  tonics  and  alteratives  are  of  course 
indicated.  While  they  are  peculiarly  uncomfortable,  the  aphthae 
have  no  serious  pathological  signification,  except  as  they  are  in- 
dicative of  an  atonic  condition. 


PHARYNGITIS    AND    TONSILLITIS.  6l 

CHAPTER  XIV. 

PHARYNGITIS  AND  TONSILLITIS. 

There  are  many  pathological  conditions  of  the  oral  cavity, 
and  of  the  immediately  connected  tissues  and  organs,  that  should 
fall  within  the  province  of  the  oral  physician  or  dentist,  but  which 
are  usually  relegated  to  the  general  medical  man.  When  the  time 
shall  come  in  which  no  man  will  be  allowed  to  enter  upon  oral 
practice  who  is  not  thoroughly  qualified  to  treat  all  oral  condi- 
tions, dentistry  will  occupy  a  very  different  place  in  general  esti- 
mation from  that  of  to-day,  and  there  will  be  plenty  of  room  for 
all  the  competent  men  whom  it  will  be  possible  for  the  colleges 
to  turn  out.  At  present,  diseases  of  the  pharynx  are  usually  sup- 
posed to  be  beyond  the  scope  of  the  dental  practitioner.  And  yet 
there  are  no  specialists  to  whom  such  affections  should  so  naturally 
fall,  and  there  are  none  who  have  such  opportunities  for  the  observa- 
tion and  detection  of  pharyngeal  lesions.  It  but  needs  that  these 
shall  be  brought  within  the  limits  of  his  practice,  and  that  he  shall 
properly  qualify  himself  for  their  treatment,  to  bring  great  benefits 
to  both  the  dentist  and  the  people. 

The  pharynx  is  a  pouch,  largely  aponeurotic,  zvhich  is  divided 
into  two  parts  by  the  soft  palate.  It  has  seven  openings — that  of  the 
mouth,  the  two  Eustachian  tubes,  the  larynx,  the  esophagus,  and  the  two 
nares.  Its  diseases  are  mainly  those  of  the  mucous  membrane.  There 
is  no  more  common  affection  than  angina  simplex,  a  common 
sore  throat,  the  effect  of  that  inflammation  that  we  call  a  cold. 
It  is  accompanied  with  irritation,  huskiness,  and  pain  in  swallow- 
ing, and  its  remedy  is  in  cleansing,  antiseptic,  astringent-stimulat- 
ing, and  anodyne  gargles,  a  solution  of  chlorate  of  potash  being  that 
most  commonly  used. 

A  considerable  proportion  of  pharyngeal  affections  are  the 
direct  results  of  lesions  within  the  oral  cavity,  brought  about  by 
continuity  of  tissue.  There  are  certain  diseases  of  the  tonsillar 
glands  that  are  not  included  in  this  origin,  and  there  are  inflamma- 
tions dependent  upon  laryngeal  lesions  as  well,  but  a  considerable 
number  of  the  affections  are  due  to  oral  trouble.  Complications 
arising  from  impactions  of  the  wisdom  tooth  and  its  investments 


62  ORAL    PATHOLOGY   AND    PRACTICE. 

are  one  of  the  most  frequent  of  these.  Owing  to  a  lack  of  develop- 
ment, especially  in  the  length  of  the  body  of  the  lower  jaw,  fre- 
quently there  is  not  sufficient  room  for  the  eruption  of  the  tooth, 
and  it  becomes  imbedded  in  the  tissues,  a  constant  source  of  irri- 
tation. Sometimes  the  inflammation  about  it  is  so  intense  as  to 
prevent  the  opening  and  closing  of  the  mouth.  At  times  there  is 
a  breaking  down  of  tissue,  and  suppuration  ensues.  From  the 
initial  point  of  the  lesion,  dark-red  lines  extending  down  into  the 
pharynx  may  be  observed,  and  there  is  a  distinct  and  sometimes 
an  acute  inflammation  of  the  pillars  of  the  fauces,  with  great  dis- 
comfort, or  even  acute  pain. 

In  cases  of  cleft  palate  there  are  almost  always  complications 
involving  the  anterior  and  posterior  nares.  When  these  are  pre- 
sented to  the  dentist  he  usually  proceeds  to  the  construction  of  some 
prosthetic  apparatus  for  the  purpose  of  supplying  the  loss,  without 
any  preliminary  attention  to  the  soft  tissues  themselves.  In  all 
cases  of  complete  or  incomplete  cleft,  the  pharyngeal  walls,  as  well 
as  those  of  the  nasal  cavity,  are  in  an  irritable,  inflamed,  hyperemic 
state.  This  could  not  well  be  otherwise,  because  they  are  not  pro- 
tected by  the  usual  palate,  and  are  subjected  to  the  irritating  action 
of  food  and  drink  every  time  it  is  taken.  Not  infrequently  there 
are  excoriations  and  abrasions  of  the  edges  of  the  palatal  cleft,  with 
degenerative  conditions  of  the  mucous  membrane  of  the  posterior 
nares  that  require  active  treatment.  The  oral  physician  or  surgeon 
seldom  notices  them,  because  they  do  not  form  a  part  of  the  regular 
practice  to  which  he  confines  himself. 

Inflammations  of  the  pharyngeal  tissues,  arising  from  the 
changes  in  the  neural  currents  commonly  called  "taking  cold,"  are 
quite  common.  If  the  tongue  is  depressed  by  placing  upon  it  a 
broad  spatula,  the  whole  pharyngeal  cavity  will  appear  of  a  bright- 
red  color,  with  the  parts  considerably  swollen.  The  uvula  will 
appear  lengthened  and  pendulous.  There  will  be  a  dryness  in  the 
fauces,  with  huskiness  of  the  voice  and  considerable  pain  on  swal- 
lowing. The  Eustachian  tube  will  apparently  be  closed,  and  the 
hearing  will  be  materially  affected. 

These  simple  follicular  inflammations  usually  result  in  a  ready 
resolution,  but  their  time  may  be  cut  short  by  proper  remedial 
measures.  If  there  are  no  abscesses  or  deep  erosions,  hot  pedi- 
luvia  should  be  resorted  to,  with  saline  cathartics  and  diaphoretics. 


PHARYNGITIS    AND   TONSILLITIS.  6 


O 


The  latter  class  of  remedies  is  of  importance,  and  a  general 
diaphoresis  will  usually  greatly  hasten  a  cure.  Twenty  or  thirty 
grains  of  potassium  bromide,  with  five  drops  of  tinct.  veratrum 
viride,  may  be  taken  in  a  small  glass  of  water,  when  the  patient 
should  go  to  bed  and  cover  up  warm.  A  gargle  of  chlorate  of 
potash  may  be  used  if  the  attack  is  not  very  acute.  If  there  is  any 
infection,  an  antiseptic  gargle,  such  as  a  teaspoonful  of  phenol 
sodique  in  a  glass  of  water,  or  five  grains  of  chloride  of  zinc  to  the 
ounce  of  water,  may  be  employed.  If  there  are  excoriated  surfaces 
they  may  be  touched  with  a  cauterant. 

Tonsillitis. 

The  tonsils  are  sometimes  severely  attacked  by  parenchyma- 
tous inflammation.  Where  this  is  comparatively  slight,  a  careful 
examination  may  be  necessary  to  distinguish  it  from  some  forms 
of  pharyngeal  inflammation.  But  there  are  instances  in  which 
the  tonsils  become  so  greatly  inflamed  as  to  prevent  swallowing 
and  to  impede  breathmg,  and  active  scarification  becomes  a  neces- 
sity. Usually,  however,  the  swelling  may  be  allayed  by  a  phenol- 
sodique  gargle,  or  one  of  which  sodium  bicarbonate  forms  the 
base.  If  there  is  much  pain  the  tonsils  may  be  painted  over  with 
a  cocain  solution.  If  suppuration  ensues  despite  all  measures  to 
prevent  it,  the  pus  should  be  voided  as  soon  as  possible,  and  the 
usual  antiseptic  treatment  follow. 

In  tonsillitis  of  an  especially  acute  character  Prof.  F.  J.  S. 
Gorgas  recommends  the  following  prescription: 

5 — Acidi  gallici,  gr.  xl; 

Liq.  sodas  chlorinatse,  oij ; 

Glycerol,  oij ; 

Aquae  dest.,  oviij.     M. 

Sig. — To  be  used  as  an  antiseptic  and  astringent  gargle. 

It  should  not  be  forgotten  that  the  tonsils  are  frequently 
marked  with  deep  sulci  and  furrows,  especially  if  they  have  been 
the  seat  of  repeated  attacks  of  septic  inflammations.  These  de- 
pressions form  favorable  harbors  for  the  proliferation  of  different 
forms  of  pathogenic  and  saprogenic  bacteria.  When  this  condi- 
tion is  observed,  great  care  should  be  exercised  to  keep  the  exter- 
nal surfaces  of  the  glands  in  an  aseptic  condition,  lest  the  sup- 
purative condition  commonly  called  quinsy  become  chronic. 


64  ORAL    PATHOLOGY    AND    PRACTICE. 

CHAPTER  XV. 

DISEASES  OF  THE  TONGUE. 

Properly  read,  the  appearance  and  superficial  condition  of  the 
tongue  is  an  index  to  most  gastric  and  to  many  other  general  dis- 
turbances. In  health  it  is  of  a  delicate  whitish  pink  color,  smooth 
and  moist.  Any  departure  from  this  appearance  indicates  a  patho- 
logical condition,  not  necessarily  of  the  organ  itself,  but  of  others 
whose  disturbed  state  is  reflected  upon  the  tongue,  and  especially 
of  functional  aberrations  which  interfere  with  digestion.  It  may 
be  covered  with  the  so-called  "fur,"  which  is  a  coating  made  up  of 
the  epithelial  scales  that  have  not  been  thrown  off,  of  certain  gran- 
ular matters,  of  inspissated  or  degenerate  mucus,  and  of  detritus. 
The  investment  of  the  tongue  with  this  coating  always  commences 
at  its  base,  and  gradually  invades  the  dorsum  until  the  tip  is 
reached.  The  clearing  up  of  the  tongue  during  convalescence  is 
from  the  tip  and  borders  toward  the  base,  so  that  the  progress  or 
recession  of  this  coating  will  furnish  an  index  to  the  condition  of 
the  patient  from  day  to  day.  A  furred  tongue  is  a  symptom  of  a 
defective  circulation. 

In  addition  there  are  certain  well-established  appearances  that 
are  indicative  of  special  pathological  conditions : 

Extreme  humidity — Indicates  atony,  with  anemia. 

Extreme  dryness — Nervous  irritation  or  weakness. 

Flabhiness  or  tremulousness — Extreme  weakness. 

A  grayish  white  color  after  eating — Normal  digestion. 

A  yellowish  white — Acidity,  with  biliary  irritation. 

Very  zvhite,  thick  coating  ("flannel  month'') — Intense  venous 
congestion. 

A  delicate  pinkish  red — Digestion  completed. 

A  deeper  hue  of  red — Arterial  congestion ;  irritation. 

Very  deep  dark  red — Active  inflammation. 

Bright  red,  raw  or  glased — Approaching  fatal  exhaustion. 

Brownish  red,  zvith  thick  dry  coating — Prostration;  danger. 

Black,  not  a  deep  hue — Blood  poisoning;  pyemia. 

Bluish  tinge — Cyanosis;  lack  of  oxygen. 

The  indications  upon  the  tongue  of  a  dangerous  condition  are 


DISEASES    OF   THE   TONGUE.  65 

tremulous  action,  extreme  dryness,  blueness,  a  very  red,  shining  or 
glazed  aspect,  and  heavy  furring  of  a  dark  or  black  hue. 

In  considering  the  tongue  as  a  diagnostic  organ,  however,  its 
indications  are  not  to  be  depended  upon  alone.  Its  appearance 
should  always  be  studied  in  connection  with  other  symptoms, 
which  may  dominate  the  decision.  It  is  to  be  considered  only  as 
an  important  auxiliary  in  arriving  at  a  conclusion. 

Of  itself  the  tongue  is  subject  to  many  pathological  conditions. 
It  is  manifestly  impossible  within  the  limits  of  a  work  like  this  to 
consider  all  these,  or  to  do  more  than  to  note  those  degenerations 
that  are  of  greatest  interest  to  the  oral  specialist.  The  remainder 
more  especially  belong  to  the  general  practitioner. 

Glossitis,  inflammation  of  the  tongue  itself,  whether  sympa- 
thetic or  idiopathic,  is  a  disorder  which  may  occur  at  any  time. 
When  it  is  the  result  of  some  injury  or  traumatism,  it  especially 
appeals  to  the  oral  practitioner.  The  tongue  may  be  wounded  by 
the  careless  use  of  instruments,  and  great  inflammation  may  be  the 
result.  An  excavator  or  bur  that  has  been  used  in  a  gangrenous 
tooth  pulp  may  wound  the  tongue  and  cause  alarming  symptoms 
as  the  result  of  the  septic  infection;  a  very  short  time  may  suffice 
to  cause  such  an  intense  infiltration  that  suffocation  will  appear 
imminent.  The  swollen  tongue  may  fill  the  mouth  to  the  utmost 
point  of  distention.  The  general  system  may  sympathize  and  the 
pulse  grow  rapid,  a  feverish  condition  supervene,  and  a  state  ensue 
that  causes  the  most  intense  anxiety,  from  the  alarming  symptoms 
presented. 

An  acute  glossitis  will  usually,  however,  end  in  complete  reso- 
lution without  such  startling  symptoms.  It  may  be  necessary, 
and  it  is  usually  advisable,  to  administer  an  active  cathartic,  and  to 
promote  diaphoresis  by  means  of  potassium  bromide,  or  Dover's 
powders,  with  warm  drinks.  If  there  is  a  septic  wound  it  should 
be  opened  to  its  bottom,  to  permit  the  escape  of  any  infectious 
products.  If  the  swelling  assumes  dangerous  proportions,  no 
time  should  be  lost  in  making  deep  incisions  into  the  body  of 
the  tongue.  These  should  not  be  long  or  continuous,  but  merely 
deep  punctures  with  a  bistoury,  and  as  many  as  may  seem  indi- 
cated. 

Syphilitic  ulcers,  swellings,  cracks  and  fissures,  indurations, 


66 


ORAL    PATHOLOGY   AND    PRACTICE. 


hypertrophies,  etc.,  are  comparatively  common,  but  their  consid- 
eration need  not  engross  our  attention  at  this  time. 

Fig.  14. 


The  Tongue. 
I.  The  Circumvallate  Papillae,  or  Papillae  Maxitnas.     2.  The  Foramen  Cecum.     3.  Fungi- 
form  Papillae,  or   Papillae    Medise.      4,  5.  Filiform   Papillae,  or  Papillae  Minimae.      6.  Inter- 
tonsillar  space,  with  numerous  follicles.    7.  The  Tonsils.    8.  The  Epiglottis.    9.  TheFrenum. 


Injuries  from  the  teeth  are  not  uncommon,   and  sometimes 
result  in  degenerative  conditions  of  the  gravest  character.     The 

tongue  is  perhaps  irritated  by  the  sharp  edge  of  a  decayed  or 
broken  tooth,  and  a  thickening  of  the  tissue,  with  induration,  fol- 


DENTITION  :     GENERAL    CONSIDERATIONS.  .         67 

lows,  even  though  the  mucous  membrane  is  not  broken.  The 
irritation  being  kept  up,  the  scirrhosis  increases  until  there  comes 
a  time  when  it  breaks  down  in  the  center,  an  indurated  border  yet 
remaining.  This  may  present  the  appearance  of  syphilitic  gum- 
mata,  and  may  have  consequences  almost  as  disastrous.  No  dentist 
should  leave  in  the  mouth  any  such  tooth,  if  it  falls  under  his  obser- 
vation, for  it  may  result  in  a  serious  complication.  When  such  a 
thickening  is  found  all  source  of  irritation  should  be  removed,  and 
if  it  does  not  disappear  it  may  be  necessary  to  remove  it  by  surgical 
interference,  lest  it  assume  a  malignant  form. 

If  an  eroded  ulcer  is  the  result  of  such  a  sharp  tooth,  and  if 
upon  removal  of  the  cause  it  presents  an  indolent  appearance,  a 
chloride  of  zinc  wash  of  not  more  than  ten  grains  to  the  ounce  of 
water  may  be  used,  or  one  made  by  the  addition  of  a  little  compound 
tincture  of  capsicum  in  water.  Violent,  or  drastic,  or  surgical 
measures  should  not,  however,  be  lightly  resorted  to.  Plenty  of 
time  should  be  given  for  nature  to  bring  about  a  cure,  and  general 
measures,  like  tonics  and  alteratives,  should  be  resorted  to,  lest  too 
active  local  interference  bring  about  the  very  state  that  it  is  desired 
to  avoid. 


CHAPTER  XVI.       , 

DENTITION:  GENERAL  CONSIDERATIONS. 

The  subject  of  dentition  has  not  heretofore  received  the 
thoughtful  consideration  at  the  hands  of  either  dentist  or  physician 
which  its  magnitude  warrants.  The  general  practitioner  is  apt 
either  to  consider  it  a  mere  physiological  process  which  demands  no 
attention  whatever,  save  in  a  few  very  exceptional  instances  super- 
ficially to  lance  the  overlying  gum,  or  without  special  deliberation 
heedlessly  to  charge  to  its  account  almost  any  of  the  disorders  which 
occur  coincidentally.  On  the  other  hand,  the  dentist,  like  all  other 
specialists,  is  inclined  to  discover  within  the  limits  of  his  own  field 
the  proximate  or  direct  cause  for  almost  every  ill  to  which  flesh  is 
heir.  This  is  but  natural.  His  life  is  devoted  to  the  study  of 
certain  organs,  and  he  knows  how  close  is  their  functional  relation 
to  other  parts  of  the  body.     He  is  certainly  more  likely  to  be  right 


68         '  ORAL   PATHOLOGY   AND   PRACTICE. 

than  the  man  who  has  no  special  or  intimate  knowledge  of  that 
particular  subject,  but  there  is  danger  that  he  may  exaggerate  its 
importance  as  one  of  the  factors  in  vitality.  That  which  is  nearest 
our  eye  may  eclipse  much  larger  but  more  distant  objects.  To 
learn  their  proper  relative  importance  a  view  must  be  taken  from 
another  standpoint. 

The  purpose  of  this  chapter  is  to  determine,  as  far  as  possible, 
the  influence  of  the  advent  of  the  teeth  upon  other  functions  of  the 
body,  to  point  out  the  complications  which  may  arise  in  their 
growth,  and  to  correct  the  impression  so  often  conveyed  by  physi- 
cians that  disorders  in  no  way  related  are  the  result  of  a  dentition 
which  may  be  entirely  normal.  The  author  is  but  too  well  aware 
that  he  is  not,  on  this  question,  in  entire  accord  with  either  the 
average  dentist  or  physician,  the  one,  as  he  believes,  too  often 
exaggerating,  and  the  other  misapprehending  its  functional  signifi- 
cance. If,  therefore,  he  assumes  to  speak  in  a  somewhat  contro- 
versial manner,  it  is  that  he  may  consider  the  subject  from  another 
than  his  own  standpoint.  Let  there  be  no  misconception.  He  does 
not  in  any  way  wish  to  be  comprehended  as  urging  that  dentition 
is  but  a  minor  matter,  or.  that  its  possible  importance  has  been  in 
any  way,  by  anyone  whatever,  overestimated.  It  is,  however,  quite 
possible  that  inquiry  has  been  wrongly  directed,  and  that  the  scope 
of  its  influence  has  been  in  some  instances  misconceived. 

The  period  of  dentition  is  a  transitional  one.  It  is  the  time 
when,  under  normal  conditions,  the  child  is  gradually  habituated  to 
the  reception  of  food  that  is  extra-maternal, — that  which  has  not 
already  by  the  mother  been  digested  and  transformed  into  a  pabu- 
lum which  is  adapted  to  the  undeveloped  organs  of  the  infant. 
It  should  be  comprehended  that  during  this  period  it  is  not  alone  the 
teeth  which  are  growing.  Organs  are  developing  simultaneously 
that  are  far  more  important,  in  that  they  are  absolutely  essen- 
tial to  life  itself,  and  without  which  existence  cannot  even  for  a 
short  time  be  maintained.  If  it  is  true,  then,  that  the  development 
of  the  teeth  under  usual  conditions  is  likely  to  produce  such  seri- 
ous disturbances  as  are  sometimes  charged  to  it,  what  shall  be  said 
of  the  growth  and  functional  changes  taking  place  in  the  digestive 
tract,  and  what  of  that  marvelous  transformation  in  the  heart  which 
occurs  at  birth,  or  that  of  the  genital  organs  which  takes  place  later 
in  life?     We  must  not  fall  into  the  error  of  attributine  to  the 


DENTITION  :      GENERAL    CONSIDERATIONS.  69 

growth  of  the  teeth  all  the  phenomena  of  the  period,  ignoring  the 
fact  that  other  organs  are  passing  through  a  like  developing  stage. 
It  must  be  remembered  that  the  beginning  of  the  formation  of  the 
teeth  goes  back  to  a  very  early  period  of  fetal  existence,  and  is 
contemporaneous  with  that  of  the  heart  and  the  lungs.  The  mere 
eruption  of  them  through  the  gums  is  but  a  single  incident  in  their 
progression,  due  to  rapid  growth  of  the  cementum  and  dentine, 
and  is  simply  one  of  the  eras  of  spasmodic  developmental  activity 
through  which  all  bodily  organs  pass.  Why  should  such  infinitely 
greater  stress  be  placed  upon  the  advancement  of  the  teeth  than 
upon  that  of  all  the  other  organs  of  the  body,  when,  as  is  presup- 
posed in  the  preceding  paragraphs,  no  specially  abnormal  or  un- 
usual conditions  exist? 

That  anomalous  and  unnatural  presentations  of  the  dental 
organs  are  more  common  than  are  lesions  in  other  like  developing 
ones  is  undoubtedly  the  case,  and  it  is  from  this  standpoint,  and 
from  this  alone,  that  the  magnitude  of  the  subject  is  apparent. 
But  that,  grave  as  may  be  the  complications  which  produce  certain 
definite  functional  disturbances,  to  them  shall  be  attributed  the 
most  diverse  disorders,  and  those  whose  etiology  may  be  so  much 
more  readily  discovered  in  other  functional  disturbances,  seems  not 
very  reasonable  or  rational.  The  sole  question  at  issue  is  not 
whether  dentition  may  induce  grave  systemic  disorders,  but  whether 
it  is  responsible  practically  for  all  of  them.  There  can  be  no  denial 
of  the  fact  that  it  may  produce  serious  reflex  complications. 
Phimosis  may  do  the  sarae,  but  is  it  possible  that  either  is  the  cause 
of  those  whose  origin  is  in  direct  instead  of  reflex  influences? 
Children  may,  and  often  do,  die  from  maladies  induced  by  teething. 
But  is  that  solely,  or  even  chiefly,  responsible  for  the  terrible  mor- 
tality of  childhood?  That  is  the  problem  to  which  this  and  the 
three  succeeding  chapters  are  devoted. 

It  is  urged  that  infant  mortality  may  be  very  largely  due  to  the 
lowering  of  vitality,  and  a  diminution  of  the  resistive  force  of  the 
healthy  body  against  disease.  That  the  reduction  of  the  vital 
potential  caused  by  the  nervous  strain  incident  to  irritation  of  the 
dental  papillae  may  so  weaken  function  that  when  any  digestive 
irritation  is  encountered  the  little  patient  at  once  succumbs, — this 
must  be  conceded  by  all.  But  to  make  of  it  the  principal  factor  in 
the  great  mortality  of  childhood,  the  exclusive  view  of  the  specialist. 


yO  ORAL    PATHOLOGY   AND    PRACTICE. 

to  which  objection  has  already  been  raised,  must  be  adopted,  and 
the  developmental  disturbances  which  may  arise  in  all  other  organs 
must  be  ignored.  It  also  assumes  that  in  a  large  proportion  of 
instances  dentition  is  abnormal,  an  hypothesis  that  is  by  no  means 
proved.  In  this  view  it  would  appear  that  the  influence  of  denti- 
tion in  causing  the  digestive  disturbances  to  which  the  great  mor- 
tality of  infancy  is  so^  largely  due  may  very  easily  be  exaggerated. 
That  in  reflex  nervous  action  may  be  found  the  origin  of  many 
infantile  as  well  as  adult  disturbances  it  is  one  of  the  objects  of 
these  chapters  to  demonstrate.  No  physiologist  or  pathologist  of 
intelligence  and  reflection  will  be  likely  to  lose  sight  of  this.  But 
it  is  also  the  object  to  draw  a  line  between  disorders  that  evidently 
^re  or  readily  may  be  due  to  direct  functional  disturbances,  and 
those  which  are  more  recondite  in  their  etiology.  Reflex  dis- 
turbances will  induce  reflex  symptoms,  and  the  student  is  herein 
urged  to  consider  them  very  carefully.  He  is  taught  to  distinguish 
between  the  reflex  and  the  direct,  and  that  principal  object  is  kept 
steadily  in  view.  The  appearances  objectively  presented  when 
dentition  is  not  proceeding  normally  are  detailed,  and  the  symptoms 
which  reflex  nervous  action  will  offer  are  considered.  If  a  diarrhea 
can  in  any  way  be  traced  to  dental  irritation,  no  one  will  dispute 
that  it  must  be  through  reflex  nervous  conditions,  nor  that  it  must 
present  or  be  accompanied  by  reflex  symptoms.  That  is  the  sole 
point  at  issue.  Shall  we  in  discrimination  inculcate  the  importance 
of  distinguishing  between  the  two,  or  shall  we,  without  any  special 
study  of  the  case  or  consideration  of  the  circumstances,  continue  to 
attribute  to  that  which  may  be  proceeding  normally  disturbances 
in  other  organs  in  which  we  know  function  to  be  deranged  ?  Chil- 
dren may  die  of  digestive  disorders  induced  through  reflex  dis- 
turbances of  dentition.  The  sole  question  is.  Can  we  charge  to  this 
sole  cause  all  the  frightful  mortality  of  childhood,  when  we  should 
know  but  too  well  that  other  more  powerful  factors  are  engaged  ? 


THE   DISEASES    OF   DENTITION.  :  "Jl 

CHAPTER  XVII. 
THE  DISEASES  OF  DENTITION. 

The  fact  that  a  considerable  portion  of  the  human  family  die 
before  they  have  reached  the  period  at  which  the  last  of  the 
deciduous  teeth  shall  have  been  erupted,  and  that  the  time  of 
greatest  mortality  is  that  during  which  the  teeth  usually  make 
their  appearance,  has  led  to  the  popular  belief  that  the  one  is 
necessarily  dependent  upon  the  other ;  that  dentition  is  the  almost 
exclusive  cause  of  the  high  death-rate  among  children,  instead  of 
more  frequently  being  merely  coincidental.  That  it  is  possible  for 
s  retarded  or  disturbed  dental  development  to  induce  very  serious 
derangement  has  already  been  afifirmed,  but  that  it  is  the  principal 
factor  in  inducing  the  great  number  of  deaths  that  occur  in  children 
from  digestive  disorders  can  scarcely  be  maintained.  There  are 
many  cogent  reasons  for  the  contrary  belief,  while  there  is  nothing, 
save  the  mere  fact  of  coincidence,  to  sustain  the  theory  too  com- 
monly accepted  without  inquiry  or  consideration. 

There  is  a  lack  of  comprehension  as  to  the  true  character  of 
the  diseases  that  cause  this  high  death-rate  in  children.  Digestive 
derangements  are  not  the  main  factor,  and  yet,  if  we  except 
nervous  disorders,  these  are  the  only  ones  that  can  with  propriety 
be  urged  as  the  possible  result  of  disturbances  in  dentition. 
Statistical  summaries  nowhere  give  the  cutting  of  teeth  as  a  cause 
of  death.  Although  the  reflexes  due  to  disordered  dentition  un- 
doubtedly in  some  instances  may  be  the  real  proximate,  if  not  the 
direct,  cause  of  death,  it  is  impossible  always  to  distinguish  them 
from  other  reflex  disturbances,  and,  in  any  case,  statistics  cannot 
pretend  to  present  more  than  the  immediate  cause.  Hence  they 
must  always  be.  accepted  with  these  limitations.  But,  the  fatal 
lesion  being  determined,  it  is  comparatively  easy  to  discover  whether 
reflexes  may  readily  induce  it,  and  from  these  probabilities  deter- 
mine their  influence  in  any  given  table.  For  instance,  no  one  will 
urge  that  they  can  play  any  important  part  in  the  zymotic  disturb- 
ances which  are  chiefly  chargeable  v/ith  the  majority  of  infantile 
deaths,  while  in  affections  of  the  brain,  heart,  or  kidneys  they  might 
be  frequently  responsible.  But  granted  that  a  brain  trouble  is  due 
to  reflex  irritation,  it  is  by  no  means  established  that  the  source 
lies  in  the  teeth. 


^2.  ORAL    PATHOLOGY   AND   PRACTICE. 

The  following  tables  will  be  found  very  instructive  in  the 
study  of  mortality.  They  are  derived  from  reliable  sources,  and 
are  presented  in  the  hope  that  they  will  afford  assistance  to  those 
who  desire  to  investigate  for  themselves,  rather  than  to  obtain  all 
their  information  at  second-hand.  The  traditionary  instruction 
given  in  medical  schools  is  that  the  teeth  are  the  one  important 
factor  in  producing  the  high  death-rate  of  infancy.  It  is  the 
imperative  duty  of  dentists  to  examine  the  facts,  and  to  inquire  if 
this  hypothesis  is  not  founded  in  error,  due  to  insufficient  study  and 
knowledge,  like  that  other  assumption  of  certain  medical  authori- 
ties, that  pulpless  teeth  are  the  principal  source  of  disease  of  the 
maxillary  sinus,  and  a  continual  menace  to  health. 

Percentage  of  probability  that  a  child  born  alive  will  die 
of  different  diseases. 

Phthisis 1144  Diphtheria 0049 

Diarrhea  and  dysentery 0343  Brain  diseases 1218 

Typhoid   0381  Lung  diseases 2640 

Scarlet  fever 0300  Stomach  and  liver  diseases. . .     .0524 

Whooping-cough 0151  Heart  disease  and  dropsy 0766 

Measles  0128  Kidney  diseases 0149 

This  shows  that  diseases  of  the  lungs,  which  include  phthisis, 
are  the  most  fatal,  and  that  more  than  twice  as  many  people  die 
of  brain  disease  as  of  stomach  troubles. 

Mean  age  at  death  of  peopU  dying  from  various  diseases. 

Males. 

All  causes 28.2 

Whooping-cough    1.7 

Measles    2.5 

Croup    3.1 

Diphtheria    7.7 

Scarlet  fever 5.2 

Smallpox 13.2 

Diarrhea    1 1.8 

Cholera   30-4 

Erysipelas   35-7 

Rheumatism    39.8 

Influenza   42.8 

Carbuncle   59-^ 


Females. 

Mean. 

30.8 

29-5 

1.8 

1-75 

2.8 

2.7 

3-2 

3-15 

8.1 

7-9 

5:6 

54 

10.6 

11.9 

14.9 

134 

32.4 

314 

32.8 

34-3 

41.4 

40.6 

48.8 

45-8 

57-2 

58.6 

THE   DISEASES   OF   DENTITION. 


73 


This  table  indicates  that  the  diarrheas  are  not  confined  to 
childhood,  but  that  they  are  most  destructive  in  middle  life. 

Average  infant  mortality  in  different  countries.     Percentage  of  the 
population  dying  under  five  years  of  age. 

Norway  17        France 31 


Ireland    17 

Denmark    20 

Scotland   20 

Sweden   20 

England   26 

Belgium    27 


Prussia    32 

Holland    33 

Austria    36 

Spain  36 

Russia  38 

Italy    39 


This  table  shows  that  in  the  warmer  and  more  thickly  popu- 
lated countries  infant  mortality  is  greater  than  in  those  lying 
farther  north,  and  which  have  fewer  people  to  the  square  mile. 
In  this  connection  the  following  table  will  be  of  interest: 

Death-rate  per  1000  under  increase  of  the  population  to  the  square  mile. 

Population  to  sq.  mile    166        186        379      1,718    4,449     12,357     65,823 

Death-rate  at  all  ages  16.94  19.18  21.90  24.81  28.02     32.96     38.67 

Under  5  years 37-8o  47-53  63.06  82.10  94.04  11 1.90  139.52 

This  table  shows  that  with  an  increase  in  population  the 
death-rate  in  young  children  is  very  much  greater  than  in  adults. 

Number  of  births  in  the  several  months  of  the  year  in  different 

countries,  100  being  considered  the  general  - 

normal  average. 

France. 

January    105 

February    iii 

March 109 

April   106 

May    99 

June    95 

July  96 

August   96 

September   97 

October    95 

November    97 

December 95 


;rmany. 

Spain. 

Italy. 

103 

114 

107 

105 

108 

114 

103 

112 

IIO 

100 

102 

106 

97 

100 

95 

95 

89 

89 

96 

88 

91 

98 

91 

93 

106 

98 

100 

100 

100 

98 

100 

97 

98 

99 

100 

97 

74  ORAL    PATHOLOGY   AND    PRACTICE. 

It  is  only  in  the  older  countries  that  these  statistics,  which 
are  compiled  from  government  records,  are  kept.  In  America 
the  census  reports  have  not  until  lately  been  thus  complete.  The 
lesson  to  be  learned  from  these  presentations  is,  that  while  birth- 
rates do  not  widely  differ,  the  death-rate  is  subject  to  many  contin- 
gencies. The  diseases  of  which  children  mostly  die  are  not  those 
which  could  be  materially  influenced  by  the  cutting  of  teeth,  but 
are  due  either  to  organic  lesions  or  to  contagious  disorders,  in 
neither  of  which  can  dental  disturbances  play  an}^  important  part. 
As  has  already  been  stated,  nowhere  is  the  cutting  of  teeth  statisti- 
cally given  as  the  direct  cause  of  mortality.  Although  it  may  in 
some  instances  induce  death  through  some  other  complication,  its 
influence  has  been  considered  either  too  remote  or  too  insignificant 
to  be  included  as  a  separate  cause. 

All  these  facts  should  lead  us  to  give  close  scrutiny  to  the 
assertions  of  those  who  claim  that  any  considerable  number  of 
infants  die  from  cutting  teeth.  A  distinction  should  be  clearly 
drawn  between  the  "so-called"  diseases  of  dentition,  which  may  be 
digestive  disturbances,  and  those  that  are  actually  produced  by 
mal-development  of  ^he  teeth,  whose  pathological  history  is  quite 
dififerent.  The  former  class  of  derangements  may  properly 
belong  to  the  general  practitioner,  while  the  attention  of  the  oral 
pathologist  should  be  more  particularly  directed  to  the  latter.  But 
as  it  is  essential  that  both  should  be  comprehended  to  make  a  clear 
diagnosis,  each  must  in  turn  be  considered,  and  they  will  for  con- 
venience be  divided  into  the  "so-called"  and  the  "true"  disturb- 
ances of  dentition. 


CHAPTER  XVIII. 

THE  SO-CALLED  DISEASES  OF  DENTITION. 

Those  which  we  may  denominate  imputed  diseases  of  dentition 
are  the  diarrheas,  dysenteries,  and  fevers  of  infancy,  which  are 
true  digestive  disorders,  and  instead  of  having  their  etiology  in 
the  advancing  teeth,  arise  from  improper  feeding  during  the  period 
of  most  active  development.  All  growth,  whether  in  the  vegetable 
or  animal  kingdom,  is  by  alternate  periods  of  activity  and  repose. 


THE    SO-CALLED   DISEASES    OF   DENTITION,  75 

In  plants,  winter  is  the  season  of  rest  and  of  the  gathering  of 
forces  for  the  season  of  advancement.  With  the  spring  comes 
the  period  of  growth,  when  the  organism  assumes  an  extraor- 
dinary energy.  The  leaves  are  put  forth,  and  each  twig  shoots 
out  with  an  amazing  activity.  The  whole  advance  of  a  year  is 
then  made  within  a  few  weeks.  But  the  tissue  so  developed  is 
soft  and  succulent,  without  the  woody  structure  that  gives  it 
strength  and  consistency.  The  summer,  when  increase  and  exten- 
sion have  ceased,  is  devoted  to  the  maturing  and  consolidation 
of  the  newly  formed  material,  while  in  autumn  all  the  energies 
of  the  plant  are  employed  in  perfecting  the  fruit  or  seed  by  which 
the  preservation  of  the  species  is  insured. 

The  growth  of  the  plant  is  analogous  to  that  of  the  aniinal. 
Vegetable  physiology  does  not  in  essence  differ  from  that  of  the 
sentient  being.  The  latter  has  also  its  periods  of  increase,  of  active 
expansion,  and  those  devoted  to  the  maturing  and  perfecting  of 
that  already  formed.  Many  people  have  observed  that  children, 
after  a  period  of  seeming  suspension  of  development,  may  within 
a  few  months  add  an  inch  or  more  to  their  stature.  This  is  suc- 
ceeded by  another  term  of  rest,  when  the  tissues  pass  through  a 
process  of  maturing.  It  is  well  known  that  during  these  terms  of 
rapid  growth  young  persons  are  more  liable  to  injuries  and  illnesses 
of  different  kinds  than  they  are  either  before  or  after  them.  It 
should  not  be  forgotten  that  the  teeth,  like  the  other  organs  of  the 
body,  have  their  distinct  eras,  and  that  they  develop  with  the  rest 
of  the  body,  and  not  independently  of  it.  When  the  child  is  cut- 
ting its  teeth,  at  the  same  time  it  is  practically  getting  a  new 
stomach  and  new  digestive  organs.  Local  causes  aside,  if  the 
muscles  do  not  develop,  the  jaw  and  teeth  will  not  grow,  for  all 
are  dependent  upon  the  same  digestion  and  assimilation  of  food. 

In  the  newborn  infant  none  of  the  tissues  are  sufficiently 
developed  to  perform  independent  function.  The  muscles  of  the 
legs  will  not  support  its  weight,  and  those  of  the  arm  are  not  suffi- 
ciently advanced  to  give  it  co-ordinate  action.  The  nutritive 
apparatus  is  as  yet  so  imperfectly  organized  that  it  cannot  fully 
digest  food,  and  the  child  must  be  given  pabulum  that  is  already 
jjartly  prepared  for  assimilation.  It  finds  this  in  the  greatest  per- 
fection in  the  milk  of  the  mother,  in  which  all  the  elements  necessary 
to  growth  are  held  in  solution  in  a  condition  exactly  adapted  to  the 


'jd  ORAL   PATHOLOGY   AND   PRACTICE. 

State  of  development  of  the  child.  At  birth  this  milk  is  less  highly 
organized  than  it  will  be  six  months  later.  When  the  physician 
seeks  a  wet-nurse  for  a  newly  born  infant,  he  does  not  choose 
one  whose  child  was  born  six  months  previously,  because  her  milk 
would  be  of  such  a  character  that  the  weak  organs  of  the  young 
babe  could  not  finish  its  digestion.  The  milk  of  one  who  has  been 
a  mother  for  two  months  would  be  too  highly  organized  for  the 
babe  of  a  week. 

Nature  has  made  all  provision  for  the  regular  development 
of  the  child,  and  as  its  digestive  organs  become  better  developed 
the  milk  of  the  mother  changes  accordingly,  until  by  regular 
progression,  through  successive  advancing  periods  of  growth,  the 
various  organs  are  sufficiently  perfected  for  independent  existence, 
and  food  that  is  partially  digested  is  no  longer  a  necessity  for 
healthy  functional  action.  This  will  only,  in  normal  conditions, 
occur  when  the  other  organs  are  as  far  advanced  as  the  digestive 
tract.  The  muscular  system  will  have  enough  strength  to  enable 
the  child  to  perform  necessary  motion.  The  brain  and  intelli- 
gence will  be  adequate  to  the  proper  selection  of  its  food,  while 
the  teeth  will  be  in  a  sufficiently  advanced  state  to  prepare  the 
pabulum  that  is  proper  for  its  condition.  As  after  this  the  body 
gradually  develops,  so  that  more  highly  organized  food  becomes 
a  necessity,  additional  teeth  are  given,  the  small  ones  of  childhood 
are  succeeded  by  those  larger  and  stronger,  until  with  the  period 
of  full  puberty  the  dentition  is  completed  simultaneously  with  the 
perfection  of  the  other  organs. 

TJnless  the  regular  gradation  of  food  keeps  pace  with  the 
evolution  and  progressive  growth  of  the  organs,  all  the  processes 
of  nature  are  deranged,  function  is  interfered  with,  and  disease  is 
the  result.  If  the  young  child,  with  its  digestive  apparatus  but 
little  developed,  is  given  food  too  highly  organized,  indigestion, 
with  its  consequent  vomitings,  diarrheas,  and  febrile  disturbance, 
will  be  the  result,  and  it  is  here  that  the  "so-called"  diseases  of 
dentition  largely  have  their  origin.  With  the  advent  of  the  decidu- 
ous incisors,  the  muscular  system  is  sufficiently  advanced  tO'  allow 
the  child  to  sit  erect,  and  in  the  average  family  it  is  taken  to  the 
table  at  meal-time.  The  injudicious  or  ignorant  mother  places  in 
its  mouth  some  soft  food,  fit  only  for  adults.  The  instinct  of  the 
child  teaches  it  to  reject  the  offered  dainty.     The  sense  of  taste 


THE    SO-CALLED   DISEASES    OF   DENTITION.  TJ 

has  not  yet  been  wholly  developed,  nor  will  it  be  normally  until 
the  organs  are  sufficiently  advanced  for  full  digestion,  and  so  the 
morsel  is  ejected  with  a  wry  face.  But  the  mother  persists,  and 
after  a  time  it  is  swallowed.  Perhaps  a  morbid,  abnormal  appetite 
is  stimulated,  much  as  later  in  life  one  for  whiskey  or  tobacco  or 
opium  is  acquired. 

The  bolus  having  been  swallowed,  it  must  lie  in  the  ele- 
mentary stomach  as  undigested  as  if  it  were  leather  or  rubber. 
It  is  perhaps  regurgitated,  and  thus  expelled  from  the  system. 
If  the  bad  feeding  is  persisted  in,  this  means  of  rejection  is  soon 
exhausted,  and  the  foreign  matter  remains  in  the  stomach,  a 
continual  irritant,  until  it  is  violently  passed  through  the  pyloric 
opening  and  into  the  tender  duodenum.  Thence,  by  its  irritating 
action  as  a  foreign  substance,  it  induces  the  violent  peristaltic 
movements  which,  when  kept  up  by  successive  invasions  of  the 
irritant,  become  a  pronounced  diarrhea,  possibly  to  degenerate  into 
a  dysenteric  condition,  with  final  death. 

And  this,  because  it  occurs  about  the  period  when  the  teeth 
are  erupting,  is  ascribed  to  dentition.  As  well  might  puberty  in 
the  male  be  imputed  to  the  growth  of  the  whiskers,  because  they 
begin  to  appear  at  about  this  time.  It  is  essential  that  the  oral 
pathologist  should  have  correct  views  upon  this  subject,  and  hence 
some  time  must  be  devoted  to  its  consideration.  There  are  a 
number  of  cogent  reasons  why  the  prevailing  belief  among  physi- 
cians that  diarrheas  and  other  digestive  disturbances  are  due  to 
advancing  teeth  is  erroneous. 

In  the  first  place,  their  connection  is  remote,  while  that  be- 
tween the  diarrheas  and  improper  feeding  is  so  close  that  the  proba- 
bilities are  greatly  in  favor  of  it  as  the  cause,  even  on  other  than 
physiological  grounds. 

The  growth  of  the  teeth  is  as  much  a  physiological  process 
as  is  that  of  the  hair  or  nails.  Their  development  commences 
some  time  before  birth,  and  continues  for  a  long  time  after  it. 
The  mere  erupting  of  the  organs  is  but  an  incidental  step  in  the 
process,  and  by  no  means  its  most  significant  or  important  one. 
Why  should  the  growth  of  the  teeth  not  induce  disturbances  of 
nutrition  before  birth,  if  it  does  after? 

The  so-called  diseases  of  dentition  are  confined  to  a  compara- 
tively small  portion  of  the  year,  and  that  is  precisely  the  period 


78 


ORAL    PATHOLOGY   AND    PRACTICE. 


when  a  change  in  the  food  of  infants  is  most  liable  to  be  made  in 
the  average  family,  while  dentition  goes  on  all  the  year  alike. 

There  are  as  many  teeth  cut  in  January  as  in  July,  but  the  "so- 
called"  diseases  of  dentition  are  as  one  to  a  hundred.      This  is 

Table  I. 

Death-rate,  from  All  Causes,  of  Children  under  Three  Years,  in  the 
City  of  Buffalo,  for  the  Years  1888,  i88p,  and  i8po. 


AV.  TEMP. 

JAN. 

FEB. 

MAR. 

APR. 

MAY 

JUNE 

JULY 

Aur,. 

SEPT. 

OCT. 

NOV. 

DIiC. 

DEATHS 

72° 

378 

70° 

,^' 

>° 

364 

68° 

f        ^ 

350 

66° 

/ 

33t) 

64° 

;^= 

•327 

"4 

322 

62° 

i  - 
f 

"p 

ziT' 

• 

308 

60° 

/ 

1 

\ 

\f.< 

.0 

294 

58° 

t 

f — 

/ 

\ 

\ 
\ 

280 

56° 

/ 

/ 

\ 

,         i 

266 

54° 

/5 

0 

/ 

\         t 

252 

52° 

1 

1 

238 

50° 

/ 

1 

2 

JSl 

\ 

224 

48°. 

r 

; 

\ 
\ 

210 

46° 

1 
1 

0 

196 

44° 

1 

1 

179 

/ 

1       ^ 

18^ 

42° 

1 
1 

A 

/ 

\          \ 

168 

.— 10-- 

•  —  —  ■ 

.— •« 

B  —  —  ■ 

■^-^ 

/.\ 

-/1 

^eKA6 

£  MO^ 

'Zi^lK^ 

vW^ 

\^/ry. 

>■  ^  • 

-L54._, 

38° 

i^ 

L    / 

|C 

0  V 

V39 

a 

140 

36° 

r3o_ 

13^ 

1 

\/ 

V    \ 

126 

34° 

125 

f 

V 

II 

Nj 

112 

32° 

/ 

iia 

V 

98 

30° 

1 
/ 

V3I 

'     84 

28° 

f 
J2f 

<?" 

70 

26° 

'>? 

0 

/ 

56 

24° 

> 

V' 

42 

22° 

^24 

28 

20° 

14 

The  interrupted  line  indicates  the  average  temperature,  the  continuous  line  denoting  the  rise 
and  fall  of  the  death-rate. 


THE    SO-CALLED    DISEASES    OF    DENTITION, 


79 


Table  II. 

Mortality  from  Diarrheal  Diseases  in  the  City  of  Buffalo  for  the 

Years  1888,  i88g,  and  1890  for  the  Months  Named. 


AV,  TEMP. 

MAY 

JUNb: 

JULY 

AUG. 

SliPT. 

OCT. 

NOV. 

DKATHS 

70° 

M' 

2 

217 

69° 

/iV 

210 

68° 

/  1  \ 

\ 

203 

67° 

/ 

1   \ 

\67« 

196 

66° 

/ 

1 

i8q 

65° 

k 

1 

A"   * 
\    % 

182 

64° 

9 

1 

V'74  \ 

175 

63° 

9 

1 

i 
\ 

16S 

62° 

t 

1 

% 
\ 

i6[ 

61° 

1 

1 

% 

154 

60° 

i 

1 

\60<» 

147 

59° 

1 

1 

1 

% 

140 

58° 

f 
• 

1 

\ 

133 

57° 

f 

1 

% 

1 

126 

56° 

f 

1 

1 

119 

55° 

« 

1 

\     1 

112 

54° 

h'C 

\       . 

105 

53° 

1 

\ 

\ 

98 

52° 

\ 

I 
1 

91 

51° 

V82 

\ 

1 

84 

50° 

\ 

t 

77 

49° 

\ 

( 

70 

48° 

\ 

% 
t 

63 

47° 

\ 

1 

56 

46° 

\        \ 

49 

45° 

\        \ 
\       \ 

42 

44° 

\36* 

35 

43° 

V,  1 

28 

42° 

U 

l 

21 

41° 

^ 

/ 

V 

14 

40° 

^ 

\v 

7 

39°  ■ 

\39» 

The  interrupted  line  indicates  the  average  temperature,  the  continuous  line  denoting  the  rise 
and  fall  of  the  death-rate. 


8o  ORAL    PATHOLOGY   AND   PRACTICE. 

abundantly  demonstrated  by  the  accompanying  diagrams  (see  pages 
y^  and  79),  which  represent  the  mortaHty  of  the  city  of  Buffalo  for 
three  years.  What  is  true  of  that  city  is  true  of  all  others,  except 
as  the  tables  for  the  different  months  may  be  a  little  modified  by 
latitude. 

From  November  to  May,  in  the  northern  temperate  zone, 
the  death-rate  of  children  from  diarrheas  and  other  digestive 
disturbances  is  about  the  same  with  each  month.  With  the  latter 
month  it  begins  to  rise,  shoots  upward  with  an  amazing  increase 
during  June,  and  reaches  its  highest  point  in  July.  In  August 
it  falls  slightly,  rises  a  trifle  in  September,  and  then  falls  as 
rapidly  during  that  month  and  October  as  it  rose  in  June  and 
July,  again  reaching  the  low  point  in  November,  where  it  remains 
until  the  succeeding  May.  This  is  more  or  less  true  of  all  cities. 
Statistics  show  that  the  rule  is  general,  but  it  is  especially  appli- 
cable to  the  poorer  people,  and  the  diarrheas  and  dysenteries  are 
most  fatal  in  the  wards  and  districts  in  which  they  chiefly  live. 

The  diet  of  the  average  workingman's  family  is  necessarily 
restricted  in  its  character  during  the  winter.  In  April  may  be 
seen  by  the  wayside,  and  in  the  yards  and  in  fields,  his  wife  and 
children  gathering  the  early  herbs,  dandelion,  plantain,  and  others, 
to  boil  for  greens.  These  form  a  welcome  change  of  diet  and  are 
appetizing.  What  is  grateful  to  their  own  palates,  they  argue,  must 
be  good  for  the  baby,  and  it  is  fed  from  the  family  dish.  Digestive 
disturbances  commence,  and  they  are  intensified  by  giving  it  other 
early  vegetables,  and  perhaps  stale  fruit.  There  is  a  period  of 
incubation  of  the  disease ;  it  gradually  increases  in  intensity,  but 
death  is  not  reached  until  the  hot  weather  of  July  exacerbates  the 
condition,  and  perhaps  adds  some  kind  of  fermentative  infection 
as  the  immediate  cause  of  the  death,  the  first  degenerative  step 
having  been  taken  in  the  improper  feeding  of  April  or  May. 

The  teeth  have  been  erupting  during  this  time,  and  the 
unreflective  physician,  if  he  is  called  in,  will  quiet  the  anxious 
parents  and  friends  with  the  old  plea  of  teething,  perhaps  lancing 
the  gums  when  no  tooth  is  near  eruption,  and  neglecting  the 
organs  really  at  fault,  until  the  sexton  closes  the  scene  by  burying 
the  fatal  mistake  beneath  the  churchyard  turf. 


TREATMENT    OF   THE    SO-CALLED   DISEASES    OF    DENTITION.         8l 

CHAPTER  XIX. 
TREATMENT  OF  THE  SO-CALLED  DISEASES  OF  DENTITION, 

It  is  the  first  duty  of  the  dentist  or  the  oral  physician,  when 
he  is  called  to  examine  the  mouth  of  a  child  suffering  from  the 
imputed  diseases  of  dentition,  carefully  to  examine  and  see  if 
there  are  any  indications  of  disturbed  dentition.  A  correct  diag- 
nosis can  only  be  made  with  certainty  after  a  very  careful  con- 
sideration, not  only  of  the  child  itself  and  the  attending  symptoms, 
but  of  its  past  history,  its  sanitary  environments,  and  its  diet.  The 
age  should  be  accurately  determined,  that  it  may  be  seen  whether 
the  dental  development  corresponds  with  that  of  the  general 
system.  This  is  important,  because  it  is  not  infrequent  that  morbid 
conditions  are  ascribed  to  teething  when  the  teeth  due  at  the  time 
are  all  in  place.  A  medical  journal  reports  a  case  of  infantile  palsy 
in  a  child  more  than  three  years  of  age,  as  due  to  teething.  Both 
legs  were  cold  and  powerless.  There  was  sufBcient  irritation  of 
the  gastrocnemius  muscles  to  cause  a  permanent  contraction,  thus 
producing  a  kind  of  talipes  equinus.  Nothing  is  said  about  the 
state  of  forwardness  of  the  dentition,  but  unless  it  was  unusually 
delayed,  the  physician,  as  is  loo  often  done,  jumped  at  his  conclu- 
sions and  ascribed  to  teething  a  trouble  that  must  have  had  a 
deeper  origin. 

The  condition  of  the  gums  should  be  carefully  noted.  If  they 
are  normal,  without  any  special  inflammation  or  thickening,  we 
should  look  elsewhere  for  the  source  of  the  irritation.  It  should: 
be  remembered  that  the  gum  is  naturally  very  hard  and  dense,  from: 
the  large  amount  of  fibrous  tissue  in  it.  Normal  growth,  when; 
the  tooth  is  near  the  point  of  emergence,  will  find  the  gum  whitish,, 
glistening,  and  tense  in  appearance.  There  may  be  such  a  condi- 
tion of  impermeability,  of  toughness  and  hardness  in  the  gum  that 
the  advancing  tooth  is  retarded  thereby,  and  hence  undue  pressure 
is  brought  to  bear  upon  the,  as  yet,  insufficiently  protected  pulp, 
thus  inducing  reflex  nervous  disturbances ;  but  unless  there  are 
either  general  or  local  disturbances  that  seriously  interfere  and  re- 
quire immediate  attention,  the  tooth  easily  makes  its  way  through 
the  gums,  by  their  absorption  under  the  slight  but  continual  pres- 
sure induced  by  the  developing  roots  which  lift  the  crown. 

7 


82  ORAL  PATHOLOGY  AND  PRACTICE. 

A  clear  distinction  should,  then,  be  made  between  those  dis- 
eases which  are,  or  even  may  be,  the  results  of  improper  feeding", 
and  the  nervous  disturbances  caused  by  retarded  or  impeded  denti- 
tion. Physicians  are  year  by  year  more  clearly  recognizing  this 
difference  and  governing  their  practice  accordingly;  yet  by  far  too 
large  a  proportion  of  them  still  refer  the  diarrheas  and  fevers  of 
childhood  to  teething,  and  make  no  special  efforts  to  correct  the 
vicious  diet  which  may  be  the  source  of  the  disturbance. 

The  treatment  of  the  so-called  diseases  of  dentition  properly 
comes  within  the  province  of  the  medical  man;  yet  so  frequently 
are  young  children  who  suffer  from  bad  feeding  brought  to  the 
dentist  for  advice  or  gum-lancing,  that  some  practical  general 
directions  may  with  propriety  here  be  given. 

Fig.  15. 


Normal  Appearance  of  the  Upper  Jaw  at  the  Beginning  of  the  Eruption  of  the 
Deciduous  Teeth,  showing  Distention  of  the  Bony  Walls.    (Tomes.) 

If  the  gums  present  their  natural  light  pink,  tense,  hard, 
glistening  appearance,  it  matters  little  whether  there  are  or  are 
not  indications  of  an  advancing  tooth,  the  presumption  is  that  there 
is  another  cause  for  the  trouble.  Retarded  or  disturbed  dentition 
will  usually  leave  an  index  upon  the  tissues  about  the  point  of  irri- 
tation, and  there  will  be  found  some  departure  from  the  normal  ap- 
pearance. There  probably  will  b^  local  inflammation,  turgidity,  and 
tumefaction,  with  redness  and  soreness.  In  the  absence  of  these, 
the  diet  should  be  very  carefully  looked  after,  hygienic  conditions 
inquired  into,  and  in  case  of  any  departure  from  that  which  is 
proper,  the  food  should  immediately  be  changed  and  correct  sani- 
tary conditions  established. 

If  there  is  a  simple  diarrhea,  of  not  long  continuance,  with 
little  of  pyrexia,  or  fever,  a  simple  correction  of  the  diet  will 
probably  be  sufficient.     If  the  mother  shall  have  weaned  the  child, 


TREATMENT   OF   THE   SO-CALLED   DISEASES   OF   DENTITIOX.        83 

or  her  milk  is  insufficient,  some  one  of  the  peptonized  foods 
should  be  substituted.  There  are  so  many  of  these,  chiefly  pro- 
prietary, that  it  is  scarcely  proper  to  recommend  any  one  above 
the  others.  It  should  be  something  of  a  very  simple  nature,  in 
which  digestion  has  already  been  begun  by  partial  peptonization, 
or  the  diastatic  action  of  some  proper  digestive  ferment. 

A  mild  cathartic  may  be  needed,  and  this  is  sometimes  the  first 
necessity,  that  the  stomach  and  intestines  may  be  relieved  of 
irritating  material.  Castor  oil  in  doses  of  from  one-half  to  one  tea- 
spoonful  may  be  given.  This  will  especially  be  indicated  if  the 
stools  are  of  a  green  appearance.  If,  as  will  probably  be  the 
case,  there  is  an  acid  condition,  the  following  may  be  prescribed: 

5 — Castor  oil, 

Calcined  magnesia,  of  each  equal  parts. 
Sig. — Dose,  half  teaspoonful,  to  be  repeated  in  three  hours  if  necessary. 

Or  the  following: 

I? — Pulv.  ipecac,  gr.  ss; 

Pulv.  rhei,  gr.  ij ; 

Sodse  bicarb.,  gr.  xij. 

Fiat  chart,  xii. 
Sig. — One  every  four  to  six  hours  for  a  child  of  one  year. 

If  there  are  no  special  inflammatory  symptoms,  the  following 
may  be  used  for  the  purpose  of  checking  the  discharges: 

^ — Tinct.  opii,  gtt.  xvj ; 

Bismuthi  subnit.,        oij; 

Mist,  cretse,  5jss; 

Syr.  simp.,  ojss. 

Sig. — Shake  well,  and  give  in  teaspoonful  doses  every  four  hours. 

If  spasms  are  imminent  or  present,  the  following  may  be  used : 

5 — Potas.  brom.,  gr.  iij ; 

Tinct.  cantharidis,  gtt.  iij ; 

Spts.  camphorae,  gtt.  x. 
Sig. — Repeat  p.  r.  n.  in  w^ater. 

In  simple  diarrhea,  after  an  evacuation  of  the  bowels,  the 
following  may  be  prescribed: 

5 — Bismuthi  salicylat.,     o] ; 

Pulv.  ipecac,  et  opii,   gr.  x; 

Pulv.  aromat.,  9j. 

Fiat  chart,  xii. 
Sig. — One  powder  every  three  or  four  hours  for  a  child  of  one  year. 


84  ORAL   PATHOLOGY   AND    PRACTICE. 

If  the  stools  contain  mucus  and  blood  and  are  jelly-like,  the 
following  may  be  given: 

IJ — Hydrarg.  bichloridi,     gr.  J4 ; 
Liq.  potas.  arsenitis,    gtt.  xxxij ; 
Syrupi  rubi, 

Syrupi  rhei,  aa  oij ; 

Listerine,  ad  oij. 

Sig. — Fifteen  to  twenty  drops  every  two  hours.     If  there  is  much  pain, 
add  one-half  dram  of  deodorized  tinct.  of  opium  to  the  mixture. 

If  there  is  considerable  fever,  Dover's  powder  may  be  given 
in  small  doses  of  one  to  two  grains,  or  potassium  bromide  in  five- 
grain  doses.  Sponge  baths  with  tepid  water  will  be  found  useful,, 
and  in  extreme  cases  alcohol  may  be  added. 

But  the  change  of  diet,  and  the  most  careful  sanitary  precau- 
tions as  to  the  cleanliness  of  the  nursing-bottle,  if  such  is  used, 
and  of  all  the  surroundings  of  the  child,  will  be  the  chief  care  of 
the  physician.  Lancing  the  gums,  or  other  operative  procedures, 
in  these  instances  will  not  be  found  necessary  and  should  not  be 
advised.  Usually  the  case  will  be  put  in  the  hands  of  a  general 
practitioner,  but  the  dentist  should  be  competent  to  prescribe  in  his 
absence,  or  in  an  emergency. 


CHAPTER   XX. 

THE  REAL  DISEASES  OF  DENTITION. 

The  real  disturbances  of  dentition  are  the  pathological  condi- 
tions accompanying  the  advent  of  the  teeth,  in  contradistinction 
to  those  which  arise  from  improper  feeding.  Both  are  sometimes 
of  the  most  serious  character,  but  their  origin  and  the  phenomena 
that  they  exhibit  are  quite  different.  Usually,  with  the  eruption 
of  the  tooth,  the  superincumbent  tissues  are  absorbed  away,  and 
give  place  to  the  erupting  organ.  It  should  be  remembered  that 
up  to  this  time  there  has  been  no  formation  of  alveolar  process; 
the  bony  walls  that  envelop  the  germ  are  very  thin  and  slight, 
and  they  are  not  closed  over  it.  (See  Figs.  15  and  16.)  There  is 
very  little  if  any  pressure,  the  fibrous  gum  tissue  offering  the  only 
obstacle  to  advancement.      In  normal  conditions  this   is   readily 


Tlir^    REAL   DISEASES    OF    DENTITION".  85 

absorbed,  but  there  are  instances  in  which,  through  some  malforma- 
tion of  the  tooth  or  imperfection  of  its  tissues,  or  perhaps  because 
of  local  disturbances,  considerable  pressure  is  exerted  upon  the 
tooth  pulp,  which  at  this  stage  of  growth  forms  the  greater  part  of 
the  contents  of  the  crypt,  and  upon  which  the  enamel  and  dentinal 
cap.  already  formed  is  resting. 

In  such  instances  the  tissues  will  not  be  in  their  normal  state, 
and  will  be  predisposed  to  inflammatory  conditions.  The  tooth 
pulp  will  be  especially  irritable,  and  will  respond  to  comparatively 
feeble  impressions. 

Fig.  16. 


Normal  Appearance  of  the  Lower  Jaw  at  the  Period  of  the  Beginning  of  the 
Eruption  of  the  Deciduous  Teeth,  showing  the  Distention  of  the  Bony  Walls 
AND  the  Natural  Apertures  in  the  Jaw  through  which  the  Teeth  are  Thrust. 
Alveolar  Process  not  yet  Formed:  Rami  not  fully  Developed.    (Tomes.) 

The  pressure  that  may  be  exerted  upon  the  susceptible  pulp 
in  such  instances  may  cause  serious  complications,  but  these  will 
necessarily  be  of  a  reflex  nervous  character.  The  irritation  to  the 
delicate  pulp  tissue  will  react  upon  other  tissues,  through  their 
nerve  connections,  and  various  functions  may  be  disturbed.  A 
diarrhea  may  possibly  be  the  consequence,  but  it  will  not  resemble 
that  produced  by  digestive  disorders.  The  child  will  plainly  show 
nervous  irritation;  it  will  suddenly  wake  from  sleep,  perhaps  with 
a  scream.  There  will  be  spasms  of  the  facial  muscles,  and  inter- 
vals of  pain  will  be  succeeded  by  entire  relief.  There  will  be 
alternate  slavering  and  dryness  of  the  oral  cavity.  If  a  diarrhea 
is  at  times  present,  it  will  probably  be  succeeded  by  constipation. 
The  appetite  will  be  exceedingly  variable,  and  there  will  be 
present  that  peculiarly  fretful  condition  that  indicates  nervous 
irritability.     It  will  be  afraid  to  bite  upon  anything  whatever,  and 


86  ORAL    PATHOLOGY   AND   PRACTICE. 

will  Strenuously  resist  all  attempts  to  touch  the  gums.  This  will 
be  in  marked  contrast  to  the  condition  when,  despite  digestive 
disturbances,  dentition  is  proceeding  normally.  The  child  then 
delights  to  bite  upon  some  yielding  substance,  like  the  finger  or  a 
rubber  ring.  If  now  the  mouth  is  examined  the  gums  about  the 
advancing  tooth  will  probably  be  found  swollen,  red,  and  turgid,  and 
exceedingly  tender  to  the  touch.  The  mucous  membrane  will 
have  lost  the  pink,  tense,  and  glistening  appearance  of  health, 
and  will  plainly  show  its  disturbed  state.  During  examination 
the  child  will  perhaps  scream  hysterically,  and  plainly  indicate  its 
exalted  nervous  excitement. 

When  these  symptoms  and  appearances  are  present,  no  time 
should  be  lost  in  extending  surgical  aid.  In  view  of  the  consid- 
erations advanced  in  Chapter  XVI,  and  the  possibility  of  the  more 
serious  complications  which  may  arise  from  reflex  nervous  dis- 
turbances of  dental  origin,  the  occurrence  of  these  indications 
should  be  looked  upon  as  of  the  gravest  character,  and  the  most 
exhaustive  examination  of  the  dental  condition  should  be  instituted. 
The  general  state  of  advancement  of  the  teeth,  in  comparison 
especially  with  the  development  of  other  organs,  should  be  at  once 
heedfully  observed,  and  if  any  tooth  is  probably,  or  even  possibly, 
due  its  condition  should  be  accurately  ascertained.  Full  and  free 
lancing  of  the  gums  has  so  often  brought  relief  as  by  magic  that  it 
should  be  resorted  to  even  when  not  positively  indicated.  The 
mere  wound,  with  the  local  loss  of  a  small  quantity  of  blood,  has 
been  known  to  bring  instant  relief  when  the  most  drastic  medical 
remedies  have  entirely  failed. 

Prompt  and  deep  scarification  over  any  advancing  tooth  should 
be  made,  to  divide  the  swollen  gums  and  disengage  the  tooth. 
A  crucial  incision  is  usually  best,  if  it  be  a  molar,  while  a  longitudi- 
nal one  may  answer  for  an  incisor.  In  either  case  it  should  be  deep 
enough  thoroughly  to  divide  all  the  tissues  over  the  tooth,  and 
extensive  enough  to  free  it.  If  there  is  any  overlapping  oper- 
culum of  bone,  this  should  be  divided,  for  it  will  be  the  greatest 
obstacle  in  the  way  of  the  tooth  eruption. 

This  will  usually  be  sufficient  to  give  immediate  and  entire 
relief.  If  the  diagnosis  of  the  condition  was  correct,  and  the 
incisions  sufficient  to  disengage  the  whole  tooth,  the  change  that 
ensues  will  sometimes  be  fairly  startling.     It  may  be  well  to  give 


DENTAL    CARIES.  8/ 

a  small  dose  of  potassium  bromide  (two  to  five  grains),  or  an  enema 
of  chloral  hydrate  (five  to  ten  grains),  in  water,  to  quiet  the 
nervous  excitement  and  induce  sleep,  but  usually  this  will  not 
be  found  necessary,  the  removal  of  the  cause  of  irritation  being 
sufficient.  There  may  occur  instances  in  which  the  child  is  in 
spasms,  or  in  convulsions,  and  the  administration  of  chloroform 
necessary  for  their  control  before  surgical  measures  can  be  safely 
resorted  to,  in  which  case  there  should  be  no  hesitation  on  the 
part  of  the  operator. 

The  instrument  best  adapted  to  the  division  of  the  tissues 
over  advancing  teeth  is  the  curved  and  pointed  bistoury.  It  would 
be  difficult  to  devise  a  worse  one  than  the  ordinary  double-edged 
ovoid  lancet,  which  cannot  be  made  to  cut  at  its  extreme  point. 
Something  that  can,  if  necessary,  he  forced  deep  down  into  the 
tissues  at  its  point,  and  then  drawn  toward  the  operator,  is  essential. 
A  pushing  force  should  never  be  resorted  to,  as  control  of  the 
instrument  cannot  be  maintained,  and  there  is  serious  danger  of 
wounding  surrounding  tissues  by  its  employment. 


CHAPTER  XXL 
DENTAL  CARIES. 


A  POPULAR  impression  has  long  existed  that  caries  of  the 
teeth  is  of  modern  origin,  and  that  it  is  due  to  an  artificial  mode 
of  life,  to  a  departure  from  the  laws  of  nature,  and  to  factitious 
environments.  It  has  been  held  that  our  early  progenitors  knew 
not  the  pains  of  toothache,  and  retained  their  dental  organs  to 
a  late  period  of  life.  The  application  to  these  fanciful  speculations 
of  the  facts  evolved  by  actual  observation  has  shown  that  this 
is  an  error,  and  that  there  is  not  now  and  there  never  has  been 
a  pathological  condition  so  universal  throughout  animal  life  as 
is  caries  of  the  teeth,  for  it  is  by  no  means  confined  to  man.  There 
are  few  of  our  domestic  animals  in  whose  mouths  careful  exam- 
ination will  not  reveal  some  form  of  oral  disease,  and  among  them 
caries  plays  an  important  role.  Nor  is  it  confined  to  domestic 
animals;  the  author  has  in  his  possession  many  skulls  illustrating 


oral  pathology  and  practice. 
Fig.  17. 


Caries  in  the  Lower  Animals.    Teeth  of  a  Baboon  (Cynocephalus)  from  a  Skull  in 
THE  Possession  of  the  Author. 

Unfortunately  the  cut  shows  but  a  small  portion  of  the  decay.    There  were  but  three  sound 
teeth  (lower  incisors)  in  the  whole  denture. 


DENTAL    CARIES. 


89 


this,  among  them  being  that  of  an  old  male  gorilla,  with  extensive 
decay  of  the  teeth,  and  also  connecting  alveolar  and  antral  abscesses, 
with  necrosis  of  the  superior  maxilla. 

No  people  have  yet  been  found  among  either  civilized  or 
savage  races  in  which  dental  caries  was  not  prevalent.  Even  the 
most  ancient  had  no  immunity,  and  the  skulls  of  Egyptian  mum- 
mies, four  thousand  years   old,   exhibit  the   same   decay  that   is 

Fig.  18. 


Dental  Caries.      Penetration  of   the  Tubuli   by  Micro-Organisms.    (Miller.) 
Early  stage  shown  by  differential  staining,  only  the  organisms  themselves  being  apparent. 
Very  highly  magnified. 


observable  to-day.  Hence  we  are  not  dealing  with  a  condition 
that  depends  upon  recent  degeneration  when  we  attempt  the 
consideration  of  the  subject.  It  is  as  old  as  the  human  race,  and 
has  probably  caused  more  of  pain  and  distress  to  the  human  family 
than  any  other  disease  with  which  man  is  afiflicted. 

It  would  naturally  be  expected  that  a  condition  so  universal, 
so  ancient  in  its  origin,  and  so  distressing  in  its  results  would 
have  been  carefully  studied,  and  long  sir.ce  thoroughly  compre- 
hended.    The  fact  really  is,  that  until  within  fifteen  years  almost 


90 


ORAL    PATHOLOGY   AND   PRACTICE. 


nothing  was  known  of  the  real  etiology  of  caries,  or  of  the  changes 
it  involved.  Speculation  there  had  been  in  abundance,  and  many 
ingenious  theories  had  been  evolved,  none  of  which  satisfied  the 
existing  conditions.  It  is  within  the  memory  of  even  compara- 
tively young  practitioners,  when  at  our  dental  associations  and 
meetings  the  most  contradictory  hypotheses  were  advanced.  It 
was  declared  to  be  the  efifect  of  an  inflammatory  process  of  the 
tooth  tissues.  It  was  attributed  to  mineral  acids  that  dissolved  out 
the  calcic  salts  of  the  teeth.  It  was  by  some  believed  to  be  due 
to  a  perverted  nutrition,  whereby  there  was  a  breaking  down 

Fig.  19. 


Dental  Caries.    Penetration  of  the  Tubuli  by  Micro-organisms.    (Mummery.) 


instead  of  a  building  up  of  tooth  elements.  It  was  claimed  to  be 
the  effect  of  a  lack  of  mineral  elements  in  the  food  during  the 
period  of  growth.  It  was  urged  that  it  is  the  effect  of  electrolytic 
currents  generated  in  the  mouth  of  sufhcient  electrical  energy  to 
decompose  tooth  substance.  In  fact,  the  etiology  of  caries  was  a 
common  battle-ground  on  which  the  advocates  of  the  different 
theories  met  for  polemical  disputation  without  the  possibility  of 
victory  for  either  combatant  through  the  positive  establishment  of 
any  special  hypothesis. 

With  the  comprehension  of  the  true  principles  of  fermenta- 
tion and  the  advance  of  bacteriological  knowledge,  light  began 
to   dawn   on   the    dark   places,   until   at   last,   by   the   exhaustive 


DENTAL    CARIES.  9I 

researches  of  Prof.  Dr.  W.  D.  Miller,  an  American  dentist  resident 
in  Berlin,  the  problem  of  the  ages  was  finally  solved,  and  the 
true  nature  of  dental  caries  was  determined.  It  was  found  that 
those  who  had  described  it  as  a  decalcification  through  the  action 
of  an  acid  were  partially  correct,  but  greatly  mistaken  as  to  the 
source  of  the  acid.  The  advocates  of  the  vital  hypothesis  had  a 
section  of  the  truth,  but  not  enough  upon  which  to  base  a  practice. 
Electrical  action  had  nothing  whatever  to  do  with  it. 

Miller  demonstrated  that  dental  caries  is  due  to  a  number  of 
factors,  but  the  principal  and  basal  one  is  the  growth  of  oral 
bacteria. 

Fig.  20. 


Dental  Caries.    Enlargement  of  the  Tubuli  by  the  Action  of  Bacteria.   (Miller.) 

It  has  been  shown  in  a  previous  chapter  that  the  mouth  is 
especially  adapted  to  the  growth  of  micro-organisms.  Here  are 
found  the  proper  temperature,  the  most  fitting  media,  and  the 
required  moisture;  the  temperature  is  as  evenly  maintained  as 
it  can  be  in  any  incubator,  while  the  proper  soil  for  their  prolifera- 
tion is  always  provided.  The  various  foods,  especially  the 
starches,  will  by  the  action  of  the  ferments  of  the  mouth  be 
changed  into  forms  admirably  adapted  to  the  growth  of  the  acid- 
forming  bacteria.  Of  some  of  these  Miller  made  cultivations, 
analyzing  their  by-products,  and  he  found,  as  the  result  of  the 
proliferation  of  some  special  organisms,  lactic  acid.  Further  obser- 
vation enabled  him  specifically  to  point  out  the  exact  method  by 
which  caries  is  produced,  which  is  as  follows : 


92  ORAL    PATHOLOGY    AND    PRACTICE. 

In  the  sulcus  of  a  tooth,  or  between  two  teeth,  or  in  any  pit 
or  irregularity  of  its  surface,  food  lodges.  By  the  action  of  some 
ferment  this  is  perhaps  changed  into  a  fermentable  sugar.  This 
forms  a  suitable  medium  for  some  of  the  bacteria,  and  it  is  perhaps 
at  once  infected  with  certain  acid-producing  fungi,  which  in  their 
growth  split  up  the  fermentable  sugar,  building  into  their  own  sub- 
stance such  elements  as  are  necessary,  and  leaving  the  remainder  to 
form  new  combinations,  or  by-products,  one  of  which  may  be  lactic 
acid.  This  acid,  especially  active  in  its  nascent  or  formative  condi- 
tion, attacks  the  teeth,  dissolving  out  the  calcic  salts,  and  forming  a 
depression  in  which  more  food  lodges,  to  pass  through  the  same 
changes  and  to  be  in  turn  decomposed  by  new  colonies  of  bacteria, 
thus  forming  more  acid  to  continue  the  destructive  work. 

Fig.  21. 


s^ 


Dental  Caries.  Cross-section  showing  Melting  Down  of  the  Intertubular 
Substance  and  the  Formation  of  Minute  Cavities  through  the  Action  of  Micro- 
organisms.   (Mummery.) 

The  dissolving  out  of  the  calcareous  parts  of  the  tooth 
leaves  behind  the  organic  or  living  portion,  which  may  pass 
through  inflammatory  or  degenerative  stages,  finally  to  be  de- 
stroyed by  putrefactive  organisms.  This  is  the  essential  principle 
of  Miller's  discovery.  The  enamel  once  penetrated  by  the  pro- 
ducts of  the  growth  of  the  vegetable  fungus,  the  progress  of  the 
disorganization  is  more  rapid. 

The  bacteria  penetrate  the  dentinal  tubuli  (see  Figs.  18  and 
19) ;  the  acid  generated  within  them,  through  the  action  of  the 


DENTAL    CARIES. 


93 


micro-organisms,  enlarges  the  tubules  (see  Figs.  20  and  21),  melt- 
ing down  two  or  more  into  one,  thus  forming  minute  chambers  or 
cavities  in  the  dentine  (see  Fig.  22),  which  ultimately  are  blended 
into  a  yet  larger  one,  and  thus  decay  proceeds.  Microscopical  ex- 
amination shows  these  small  spaces  to  exist  at  a  considerable  dis- 
tance beyond  that  which  is  actually  broken  down,  and  to  account 
for  the  friable,  crumbling-  dentine  beyond  the  margin  of  the  cavity 
proper. 

Fig.  22. 


:«^ 


■;*   ►. 


Dental  Caries.    The  Formation  of  Minute  Cavities  through- the  Melting  Down 
OR  Liquefaction  of  the  Intertubular  Substance.    (Miller.) 

The  area  denominated  by  Miller  "the  zone  of  infected  dentine" 
is  that  pervaded  by  the  organism,  but  in  which  the  dissolving  out 
of  the  calcareous  inorganic  matter  of  the  tooth  has  not  yet  fairly 
commenced. 

Yet  farther  into  the  structure  of  the  tooth  have  penetrated  the 
bacteria,  filling  the  tubuli  without  having  distended  them.  Not 
infrequently  a  number  of  these  distinct  zones  of  infection  or 
caries  are  seen  in  their  different  stages,  and  readily  traced.  They 
are  all  the  result  of  tooth  infection  and  tooth  decalcification  through 
the  action  of  bacteria. 

Miller,  having  demonstrated  the  true  nature  of  this  disease 


94  ORAL   PATHOLOGY   AND    PRACTICE. 

by  analytical  methods,  next  attempted  a  kind  of  synthesis,  arriv- 
ing at  the  same  result,  thus  by  an  independent  process  proving 
the  correctness  of  his  previous  observations.  Obtaining  a  pure 
culture  of  a  bacillus  of  decay,  he  immersed  an  extracted  tooth 
in  a  proper  culture  solution,  and  with  the  utmost  solicitude  keeping 
it  in  the  proper  condition  and  at  the  exact  temperature,  he  infected 
it  with  the  bacillus  and  produced  true  caries  outside  the  mouth 
and  so  removed  from  all  physiological  or  vital  connections.  He 
thus  demonstrated  that  caries  is  not  a  vital  process,  and  that  the 
proliferation  of  the  bacillus  under  proper  conditions  will  produce  it 
as  readily  outside  the  body  as  in  it  (see  Fig.  23). 

It  must,  then,  be  accepted  as  finally  proven  that  dental  caries 
is  the  result  of  an  infection,  and  a  true  germ-produced  disease. 
It  is  essentially  a  septic  condition,  and  its  medicinal  treatment 
must  be  antiseptic.  All  prophylaxis  must  be  in  this  direction, 
and  the  general  principles  of  Listerism  are  as  applicable  to  caries 
as  to  the  treatment  of  wounds.  To  proceed  farther  than  this  in 
the  consideration  of  the  etiology  of  dental  caries  would  be  outside 
the  scope  of  this  work. 


CHAPTER  XXH. 
THE  PATHOLOGY  OF  DENTAL  CARIES. 

Physiologists,  pathologists,  and  histologists  are  sometimes 
inclined  to  consider  the  teeth  as  organs  isolated,  dissociated  from 
the  rest  of  the  body,  and  as  of  such  dissimilar,  diverse  characteristics 
that  their  relation  to  other  tissues  is  but  a  minor  factor  in  their 
study.  Dental  practice  has  been  too  exclusively  confined  to  the 
teeth  themselves,  reputable  practitioners  asserting  openly  that  there 
is  no  need  for  the  dentist  to  study  general  anatomy  or  physiology, 
and  protesting  against  everything  save  the  very  narrowest  and 
most  restricted  teaching  in  our  colleges.  Almost  unconsciously 
the  great  body  of  practitioners  have  been  led  to  think  of  the  teeth 
as  segregate  organs.  There  are  many  of  our  number  who,  while 
claiming  professional  relationship,  treat  their  vocation  as  exclu- 
sively mechanical,  and  unwittingly  debase  their  own  condition  to 
that  of  a  mere  artisan. 

The  teeth  are  true  modifications  of  bone.  The  study  of  com- 
parative dental  anatomy  teaches  through  what  gradations  they 


THE   PATHOLOGY   OF    DENTAL    CARIES.  95 

have  passed  in  their  evolution ;  very  many  of  the  intermediate  steps 
are  recorded  in  the  oral  or  pharyngeal  cavities,  and  even  in  the 
gastric  regions,  of  animals  now  extant.  In  some  instances  mastica- 
tion is  absolutely  performed  upon  true  bone,  of  modified  structure, 
which,  however,  is  soon  lost  if  it  is  submitted  to  any  rough  usage. 
We  sometimes  marvel  that  the  teeth  decay  as  they  do.  Were  they 
not  markedly  differentiated  in  structure  from  the  bone  of  which 
they  are  only  modifications,  they  would  not  last  as  long  as  they  do. 

Fig.  23. 


Artificial  Caries.    Cross-section.    Identical  with  Natural  Caries.    (Miller.) 

That  the  teeth  are  living  organs,  with  a  vital  dependence  upon 
other  tissues,  that  they  are  intimately  connected  with  the  rest  of 
the  body,  is  readily  indicated  by  the  fact  that  they  are  nourished 
by  the  same  blood  supply  and  receive  their  innervation  from  the 
same  nervous  system  with  the  other  organs.  It  is  true  that  they 
are  the  hardest,  densest  tissues  of  the  body,  but  in  this  they  differ 
comparatively  little  from  true  bone.  They  are  made  up  of  a 
living  matrix,  into  which  calcium  salts  have  been  incorporated 
to  give'  to  them  consistence.  They  are  developed  from  the  same 
connective  tissue  elements  with  other  analogous  tissues.  Com- 
ponently  they  only  differ  from  bone  in  having  a  little  more  of  the 
calcic  salts  and  a  little  less  of  the  living  matter,  in  this  respect  the 
several  tissues  of  the  teeth  showing  the  same  variations  that  are 


96  ORAL    PATHOLOGY   AND   PRACTICE. 

observable  in  different  kinds  of  bone.     To  illustrate  this  the  follow- 
ing table  is  presented : 

Bone.  Cementum.  Dentine.  EnameL 

Animal  matter 34.oo  32.00  28.00  3.00 

Earthy    matter 66.00  68.00  72.00  97.00 

100.00  100.00  100.00  100.00 

Calcium   phosphate 5i-04  S6.73  62.00  85.00 

Calcium  carbonate 11.30  7.22  5.50  8.00 

Calcium    fluorid '. .     2.00  1.63  2.00  3.20 

Magnesium  phosphate 1.16  0.99  i.oo  1.50 

Sodium  salts 1.20  0.82  1.50  i.oo 

This  table  gives  but  an  average  of  the  proportional  constitu- 
ents of  the  tissues.  It  would  be  well  if  a  careful  study  of  it  could 
be  made  by  every  dentist.  It  will  be  seen  that  the  same  elements 
enter  into  the  composition  of  all  the  hard  tissues. 

The  essential  variation  of  tooth  tissue  from  true  hone  is  that 
through  the  progressive  modifications  of  cementum,  dentine,  and 
enamel  there  is  a  gradual  loss  in  the  proportion  of  animal  or  organic 
matter,  and  a  proportionate  increase  in  the  earthy  or  inorganic. 
This  is  most  manifest  in  the  calcium  phosphate,  upon  which  the 
teeth  mainly  depend  for  their  density  and  hardness;  there  is 
comparatively  little  variation  in  the  relative  amounts  of  calcium 
carbonate,  magnesium  phosphate,  and  the  other  salts.  In  bone 
the  living  matter  is  more  than  half  as  much  as  the  inorganic,  while 
in  enamel  it  is  but  one-thirtieth. 

But  it  is  not  alone  in  its  constituent  elements  that  the  modi- 
fications of  tooth  from  bone  are  exemplified.  In  their  physical 
structure  the  gradation  is  still  more  marked.  In  bone  the  most 
distinguishing  feature  of  the  nutritive  apparatus  is  the  Haversian 
canals,  about  which  are  arranged  in  concentric  grouping  the  cells 
containing  the  living  matter.  These  corpuscles,  the  lacunae,  com- 
municate with  each  other  and  with  their  source  of  nutrition  by 
minute  canals,  the  canaliculi.  Each  regular  arrangement  or  system 
of  these  communicating  lacunae  is  called  a  lamella,  and  the  nutritive 
currents  are  thus  in  relation  with  all  the  tissue  cells  through  the 
canaliculi.     (See  Fig.  24.) 

The  first  modification,  or  differentiation,  is  found  in  the  ce- 
mentum, which  has  all  the  distinguishing  features  of  bone,  if  we 
except  alone  the  lamellae.  The  lacunae  are  present,  and  the  canal- 
iculi ;  even  the  Haversian  canals  are  sometimes  found.     They  are 


THE    PATHOLOGY    OF    DENTAL    CARHLS. 


97 


not  as  constant  as  in  true  bone,  but  even  in  that  they  are  not  always 
present.  The  lamellar,  concentric  arrangement  of  the  lacunae  about 
the  Haversian  canals  is  alone  lacking,  and  this  is  the  case  even 
when  these  vascular  canals  are  found  in  the  cementum.  The  pro- 
portion of  animal  and  earthy  matter  has  been  but  slightly  changed, 
the  variation  between  different  bones  being  sometimes  greater  than 
that  between  bone  and  cementum.  Cementum,  then,  essentially 
differs  from  bone  only  in  the  loss  of  the  lamellar  arrangement  of 
the  cells.     (See  Fig.  8.) 

Fig.  24. 


Transverse  Section  of  Bone,  showing  Lamellar  Arrangement  of  the  Lacunae  about 
THE  Nutritional  Centers. 
a.  Haversian  canals,     d,  c,  d,  Lacunae  with  branching  canaliculi.     (Gray.) 

The  next  step  in  the  differentiation  is  founi  in  the  dentine^ 
which  has  lost  the  lacunal  corpuscles  that  distinguish  cementum. 
and  bone.  As  these  contain  the  greater  proportion  of  the  living 
matter,  we  naturally  anticipate  a  considerable  reduction  in  that 
element,  and  analyses  show  that  it  has  but  about  four-fifths  the 
amount  found  in  bone,  while  the  earthy  salts  are  correspondingly 
increased.  In  its  physical  structure,  then,  dentine  retains  but  the- 
canaliculi  of  bone,  and  these  appear  in  their  analogues,  the  dentinal 
fibrillse.  Instead  of  being  the  channel  of  communication  between- 
the  lacunae,  as  in  bone  and  cementum,  they  serve  to  connect  the 
pulp,  the  analogue  of  the  medulla  of  bone,  with  the  cementum  and 
dentine,  the  dependence  not  being  very  apparent.     As  iii  bone  and 

8 


98  ORAL    PATHOLOGY    AND    PRACTICE. 

cementum,  they  are  the  medium  of  nutrition  to  the  interstitial  parts 
and  the  parenchyma.  Dentine,  then,  is  bone  modified  in  structure 
by  the  disappearance  of  the  lacunse,  as  well  as  their  arrangement 
into  lamellae.     (See  Fig.  9.) 

Finally,  enamel  is  developed, — the  densest,  hardest,  heaviest 
tissue  of  the  body.  This  is  that  which  alone  is  exposed  to  attri- 
tion, and  to  the  direct  action  of  foreign  substances. 

Bone,  cementum,  and  dentine  are  normally  protected  from 
exposure.  If  the  former  is  uncovered,  even  to  the  external  air,  the 
most  serious  consequences  may  follow.  Cementum  is  a  little,  and 
dentine  considerably  more  tolerant  of  submission  to  external  influ- 
ences. But  neither  of  them  accepts  it  without  a  pathological 
protest.  Enamel  alone  successfully  withstands  external  contact, 
and  even  that  is  in  better  condition  wiien  in  possession  of  its 
natural  covering,  cognate  to  the  skin  and  mucous  membrane, 
Nasmyth's  membrane. 

The  very  circumstances  under  which  enamel  exists  must 
demand  a  material  modification  of  structure.  Accordingly  we 
find  that  not  only  the  lacunse  of  bone  and  cementum  are  lost,  but 
the  canaliculi  of  bone,  cementum,  and  dentine  have  disappeared,  and 
the  principal  remnant  of  the  living  matter  left  is  the  microscopical 
septum  between  the  enamel  prisms.  (See  Fig.  10.)  But  it  is  not 
dead,  inert  matter.  Three  per  cent,  of  its  structure  is  animal,  so 
that,  tenuous  as  is  the  thread,  it  has  yet  a  vital  connection  with  the 
•other  living  portions  of  the  body.  The  necessities  of  its  existence 
demand  that  it  shall  have  but  a  very  minute  proportion  of  animal 
matter  to  protect  it  against  the  exposure  and  rough  usage  which  it 
must  receive,  but  still  it  is  identical  with  bone  in  its  constituent 
elements,  though  widely  variant  in  their  relative  proportions. 

Enamel  is  bone  deprived  of  the  lacuna:  and  canaliculi,  cut  off 
from  its  genetic  organ,  zvithout  independent  nutrition,  hut  still  re- 
taining a  proportion  of  that  animal  matter  without  ivhich  it  would 
he  something  alien  and  foreign. 

It  is  from  this  standpoint  that  the  tissues  of  the  teeth  are 
properly  considered.  It  is  in  their  relation  to  other  tissues,  and  as 
a  part  of  the  living  organism,  that  they  are  to  be  studied.  The 
teeth  are  not  Hfeless,  passive,  extraneous  objects.  They  have 
their  pathological  degenerations  that  demand  medicinal  agents. 
Their  treatment  cannot  properly  be  exclusively  surgical  or  op- 


THE    MEDICINAL   TREATMENT   OF  DENTAL   CARIES.  99 

erative.  It  is  true  that  their  nutrition  is  hmited  and  sluggish,  but 
it  exists,  and  must  be  considered.  They  are  amenable  to  the  same 
general  laws  with  the  rest  of  the  body.  They  contain  a  large  pro- 
portion of  inorganic  matter,  but  even  that  must  be  elaborated  in 
the  alembic  of  nature, — it  cannot  be  taken  ready-made ;  the  calcium 
phosphate  that  forms  so  great  a  part  of  their  body  is  of  organic 
origin,  and  was  distilled  by  nature's  process  from  the  organic 
matter  that  alone  can  be  used  as  food  or  built  into  the  system. 

Every  tissue  of  the  tooth,  as  is  the  case  with  all  other  tissues, 
is  the  product  of  growth,  hence  is  truly  organic,  and  the  assimila- 
tive processes  can  no  more  accept  for  nutritive  purposes  such  inor- 
ganic matter  as  crude  calcium  phosphate  than  it  can  utilize  carpet 
tacks  to  give  iron  to  the  blood,  or  lucifer  matches  to  furnish  phos- 
phorus for  the  brain.  Such  preparations  may  act  as  medicines,  to 
be  excreted  as  received,  but  their  administration  for  metabolic  pur- 
poses is  an  utter  absurdity. 

That  an  hereditary  tendency  may  be  a  factor  in  the  etiology 
of  dental  caries,  no  one  will  for  a  moment  dispute.  One  may 
inherit  a  diathesis,  a  congenital  atonicity  or  a  lack  of  resistant 
power,  but  a  bacillus  is  not  received  as  a  patrimony.  Modern 
investigation  proves  that  so  many  of  our  disorders  are  of  infec- 
tious origin  that  the  doctrine  of  heredity  must  be  materially 
modified.  It  has  been  demonstrated  by  repeated  experiment  that 
there  is  less  of  difference  in  the  structure  of  so-called  good  and  bad 
teeth  than  has  been  usually  imagined.  This  throws  us  more  directly 
back  upon  the  vis  medicatrix  natures  for  our  cures,  and  places  us 
in  a  more  intimate  relation  than  ever  with  the  vital  principle,  the 
innate  resistant  power  of  the  body,  and  directs  our  thoughts  into 
new  channels.  Dental  caries  must  be  studied  from  the  vital  stand- 
point, and  in  this  view  we  approach  the  subject. 


CHAPTER  XXIII. 

THE  MEDICINAL  TREATMENT  OF  DENTAL  CARIES. 

It  having  been  demonstrated  that  caries  of  the  teeth  is  chiefly 
due  to  the  action  of  micro-organisms,  it  naturally  follows  that  the 
remedies  employed,  aside  from  operative  ones, — which  it  is  not  the 


lOO  ORAL    PATHOLOGY    AND    PRACTICE. 

province  of  this  work  to  consider, — must  be  mainly  antiseptic. 
Were  it  possible  completely  to  sterilize,  and  to  keep  sterilized,  the 
oral  cavity,  there  could  be  no  decay.  But  this  is  impracticable, 
and  even  undesirable.  The  peptonizing  action  of  many  of  the 
bacteria  may  be  an  important  factor  in  digestion,  hence  it  would  not 
be  wise,  even  if  it  were  possible,  tO'  eliminate  them.  But  of  the 
advisability  of  at  least  limiting  their  action  there  can  be  no  ques- 
tion. The  putrefactive  organisms  certainly  can  have  no'  useful 
office  in  the  mouth,  and  common  cleanliness  demands  that  their 
growth  should,  as  far  as  possible,  be  prevented. 

Could  the  teeth  and  the  oral  tissues  be  kept  entirely  clean  and 
free  from  food  and  other  debris,  caries  would  be  so  limited  that  it 
would  be  of  little  moment.  A  carefully  polished  surface  does  not 
retain  detritus  or  debris.  Unless  there  are  depressions,  or  pits,  or 
roughness,  there  is  nothing  to  which  particles  of  food  can  cling. 
It  is  evident,  then,  that  the  first  prophylactic  measure  against  caries 
is  the  careful  polishing  of  the  teeth.  Every  deposit  upon  them 
must  be  removed,  every  pit  obliterated,  and  every  rough  surface 
made  entirely  smooth.  This  will  be  the  work  of  the  dentist,  but 
the  keeping  of  them  in  that  state  will  depend  upon  the  exertions  of 
the  individual  himself.  A  set  of  natural  teeth  in  a  state  of  perfect 
cleanliness  is  a  sight  seldom  vouchsafed  to  anyone.  Quite  as  rare 
would  be  a  patient,  just  from  the  chair  of  the  dentist,  whose  oral 
cavity  had  been  put  in  perfect  order.  The  average  practitioner 
neither  recognizes  nor  attempts  the  cure  of  half  the  pathological 
conditions  that  exist  in  the  mouths  that  he  treats.  He  fills  the 
most  conspicuous  cavities,  removes  deposits  that  actually  obtrude 
themselves  upon  his  notice,  and  ignores  the  rest.  Nor  is  it  neces- 
sarily his  own  fault  in  every  instance,  for  patients  sometimes  might 
offer  serious  objections  to  expending  the  time  and  money  necessary 
for  the  treatment  of  all  diseased  conditions  and  the  putting  of  the 
mouth  in  complete  order. 

There  is,  however,  no  excuse  for  failing  to  call  the  attention  of 
decently  clean  people  to  minute  sedimentary  precipitations  upon 
the  teeth,  depressions  or  erosions  of  their  surfaces,  "and  inflam- 
mations and  irritations  of  the  soft  tissues  about  them.  That  which 
is  neglected  is  mainly  in  the  line  of  prophylactic  treatment.  Were 
dentists  generally  more  faithful  to  duty,  their  practice  would  be 
widely  extended,  while  the  people  would  be  greatly  benefited. 


TPIE    MEDICINAL   TREATMENT   OF  DENTAL   CARIES.  lOI 

It  is  unnecessary  to  call  the  attention  of  the  student  or  practi- 
tioner to  the  most  approved  methods  of  cleaning  the  teeth.  That 
duty  devolves  upon  the  teachers  of  operative  measures.  But  the 
proper  medicinal  agents  may  be  adverted  to,  and  their  U3e  recom- 
mended. In  the  performance  of  this  task  it  is  impossible  entirely 
to  forbear  mention  of  proprietary  remedies,  whose  employment, 
when  others  can  be  substituted  for  them,  should  be  avoided; 
yet  they  are  sometimes  a  convenience,  and,  when  the  formula  is  a 
public  one,  may  be  professionally  prescribed.  A  convenient,  effec- 
tive and  unobjectionable  antiseptic  mouth-wash,  consisting  of  a 
single  simple  remedy,  is  quite  unknown.  The  most  efficient 
germicides  possess  toxic  or  caustic  properties  that  are  sufficient  to 
exclude  them.  The  best  antiseptics  are  liable  to  the  same  objec- 
tions, and  we  are  thus  forced  back  upon  the  essential  oils,  which 
must  be  combined  with  other  things  to  make  them  most  useful. 
Listerine,  borine,  borolyptol,  and  other  combinations  are  proprie- 
tary preparations,  and  therefore  objectionable  on  ethical  grounds, 
for  no  physician  has  any  right  to  make  a  prescription  for  a  patient 
unless  he  is  fully  aware  of  its  entire  character  and  thoroughly  con- 
versant with  every  drug  in  it.  He  is  paid  for  the  expert  knowledge 
of  which  the  patient  is  not  possessed,  and  he  betrays  that  patient's 
professional  confidence  if  he  does  not  exercise  due  intelligence. 
Hence  proprietary  and  secret  remedies  have  no  place  in  this  work, 
unless  their  complete  ^working  formulae  shall  have  been  submitted 
to  and  approved  by  the  author. 

For  antiseptic  use  in  the  mouth,  lysol  presents  some  advan- 
tages, and  the  following  may  be  used  with  the  tooth-brush : 
'^ — Lysol,  Sss; 

Aquae,  §xvj. 

Carbolic  acid  is  not  palatable,  and  it  possesses  toxic  properties 
that  forbid  its  use  in  strong  solutions.     But  it  is  excellent  as  an 
antiseptic,  and  the  following  formula  may  be  found  useful : 
^ — Carbolic  acid  crystals, 
Glycerol, 
Rose  water,  of  each  2  ounces. 

Five  to  ten  drops  in  a  wineglass  of  water  should  be  used  as  a 
gargle,  or  with  the  brush. 

Thymol  is  similar  in  its  action  to  carbolic  acid,  while  it  is  free 
from  its  disagreeable  odor: 


I02  ORAL    PATHOLOGY   AND    PRACTICE. 

"3J — Thymol,  4  grains; 

Benzoic  acid,  45      " 

Eucalyptol,  180      " 

Water,  2  quarts. 

This  should  be  used  as  a  gargle,  after  cleaning  the  teeth. 

The  following  is  recommended  by  Professor  Miller  as  an  anti- 
septic gargle  and  wash: 

^ — Thymol,  4  grains; 

Benzoic  acid,  45      " 

Eucalyptol,  3^  drams; 

Alcohol,  25  " 

Oil  of  wintergreen,  25  drops. 

Hydronaphthol  has  been  employed  as  an  antiseptic,  but  was 
formerly  more  used  than  it  is  at  present.     The  following  foimilla 
has  been  recommended  for  a  mouth-wash: 
IJ — Hydronaphthol,  3ij; 

Tinct.  calendulse,  •'iiv; 

Aquse  dest.,  ad  oviij. 

Any  of  these  may  be  used  with  the  tooth-brush,  or  as  a  gargle 
after  cleaning  the  teeth. 


CHAPTER  XXIV. 
PULPITIS— INFLAMMATION  OF  THE  DENTAL  PULP. 

Save  as  it  is  modified  by  surrounding  conditions,  inflammation 
of  the  pulp  does  not  differ  from  that  of  other  analogous  tissues. 
The  initial  processes  are  the  same,  and  hence  the  remarks  in  the 
section  on  Inflammation  are  applicable  to  the  condition  now  under 
consideration.  When  the  subject  of  general  inflammation  is  fully 
comprehended,  then,  and  then  only,  can  the  phenomena  presented 
in  pulpitis  be  clearly  understood.  It  is  but  necessary  to  consider 
the  peculiar  complications  brought  about  by  the  environments 
of  the  dental  pulp,  and  to  make  due  allowance  for  them,  when  the 
whole  matter  becomes  plain  and  lucid.  These  complexities  arise 
from  the  fact  that  the  tissue  of  the  pulp  is  somewhat  modified 
in  structure,  and  at  the  same  time  is  enclosed  within  unyielding, 
osseo'jus  walls,  which  in  health  form  its  sure  protection  and  in 
disease  its  rigorous  prison-house. 

Whether  or  not  the  dental  pulp,  in  its  healthy,  normal  condi- 
tion, is  or  is  not  sensitive  to  external  impressions  is  a  disputed 


PULPITIS INFLAMMATION    01"    Till-:    IJKXTAL    PULP. 


103 


question  which  cannot  be  satisfactorily  answered,  because  if  it  is 
responsive  it  is  at  once  claimed  that  it  is  not  in  a  normal  condi- 
tion. Certain  it  is  that  an  entirely  healthy  tooth  gives  no  sentient 
signs  of  the  presence  of  a  living  pulp.  It  is  sometimes  a  difficult 
matter  positively  to  diagnose  a  dead  pulp  from  a  healthy  living 

Fig.  25. 


L.F, 


P.C.— 


/■I 


\,.   \- 


li.i.rs  rKA  riNi 


Kklations  of  the  Pulp  to  thi-;  Dkntixk. 


C.£>.  Formed,  calcified  dentine.  J.£>.  Forming,  uncalcified  dentine.  i[-.j^.  Dentinal  fibrillae, 
fibers  of  Tomes, — processes  from  the  odontoblasts.  OJ.  Odontoblast  cells.  P.C.  Cells  of  the 
tooth  pulp.     (Burchard,  after  Rose  and  (iysi.) 

one  in  natural  conditions.  Both  are  equally  unresponsive  to 
ordinary  thermal  changes,  and  the  enamel  and  dentine  of  each  are 
equally  insensitive. 

Those  who  have  had  occasion  to  drill  into  or  excavate  a  tooth 
that  is  entirely  without  disturbance  of  the  pulp  tissue,  know  that 
the  dentine  is  unresponsive,  while  the  pulp  may  be,  and  often  is, 
punctured  without  the  knowledge  of  the  patient. 


I04  ORAL   PATHOLOGY   AND   PRACTICE. 

But  if  the  tooth  shall  have  sustained  an  injury,  if  there  is  reces- 
sion at  the  gums,  or  if  there  shall  have  been  any  pain  in  the  teeth 
whatever,  indicating  pulp  complications,  or  even  any  pulp  disturb- 
ance insufficient  to  produce  pain,  both  dentine  and  pulp  may  be  ex- 
quisitely sensitive.  There  are  occasional  instances  in  which  caries 
has  extended  to  the  pulp  tissue,  but  in  which  there  never  has  been 
either  pain  or  sensitiveness.  This  cannot  be  reasonably  accounted 
for  upon  the  theory  of  personal  idiosyncrasy,  for  individual  tem- 
perament will  scarcely  cover  a  departure  from  general  physiological 
laws.  There  must  be  a  good  and  sufficient  reason  for  such  an 
immunity. 

The  bloodvessels  of  the  pulp  possess  a  modified  structure,  in 
that  they  are  without  the  complete  muscular  coats  of  those  found 
in  most  parts  of  the  body.  (See  Fig.  7.)  In  this  respect  they 
resemble  those  of  the  brain,  which  also  is  a  tissue  protected  by  un- 
yielding, bony  walls,  analogous  to  those  of  the  tooth.  The  nerves 
of  the  dental  pulp  are  also  modified,  for  while  they  are  composed 
of  nervous  elements  they  lack  the  general  structure  of  those  of  most 
other  parts  of  the  body,  and  they  are  without  the  usual  sheaths. 
The  connective  tissue  of  the  pulp  is  not  especially  modified  in  struc- 
ture, but  it  must  be  peculiarly  so  in  function,  through  its  excep- 
tional blood  and  nerve  supply.  These  variations  will  be  specially 
considered  in  the  chapter  devoted  to  the  diseases  of  the  peri- 
cementum. 

The  dentine  is  without  nerve  supply,  and  yet  when  in  an  irri- 
table condition  it  becomes  acutely  responsive.  Sensation  can  only 
be  conveyed  through  the  dental  fibrillae,  whose  embryonal  structure, 
containing  all  the  elements  of  nerve  tissue,  becomes  inordinately 
responsive  in  certain  conditions.  It  is  well  established  that  forma- 
tive tissue,  embryonic  matter,  may  take  on  inflammatory  conditions, 
and  under  such  circumstances  possess  characteristics  unknown  to 
it  when  in  a  normal  state. 

It  might  be  reasonably  inferred,  then,  that  the  sensitiveness  of 
either  dentine  or  tooth  pulp  may  be  the  direct  result  of  irritation, 
and  the  inceptive  stage  of  an  inflammatory  process;  that  sensitive- 
ness of  dentine  is  but  the  result  of  that  abnormal,  irritative,  in- 
flamed condition;  that  the  peculiar  phenomena  presented  are  due  to 
the  modified  blood  and  nerve  supply,  and  that  in  its  normal  and 
healthy  state  it  may  be  quite  irresponsive  to  external  impressions; 


PULPITIS INFLAMMATION    OF    THE   DENTAL    PULP. 


lO: 


that  any  special  responsiveness  of  either  of  the  tooth  tissues  to  ex- 
ternal impressions  is  an  indication  of  a  pathological  condition,  and 
that  in  treatment  this  should  always  be  kept  in  view. 

The  pathological  changes  presented  and  the  phenomena 
exhibited  in  inflammation  of  the  tooth  pulp  will  differ  from  the 
corresponding  phenomena  in  most  other  tissues  just  so  far  as  the 
structure  of  these  latter  is  varied  and  their  environments  are  modi- 
fied by  the  tissues  with  which  they  are  in  relation.     The  peculiari- 

FiG.  26. 


Congestion  of  the  Bloodvessels  of  the  Tooth  Pulp  of  a  Dog  after 
THE  Application  of  Arsenous  Acid. 


ties  of  the  nerve  supply  will  change  the  character  of  sensation, 
while  the  special  vascular  system  will  cause  a  variation  in  the 
phenomena  presented  in  the  earlier  stages  of  inflammation,  and 
materially  modify  diapedesis.  Proceeding  upon  this  hypothesis,  it 
it  not  diflicult  to  comprehend  some  things  heretofore  unintelligible 
in  the  pathology  of  the  dental  pulp,  and  to  find  indications  that  may 
he  a  more  complete  guide  in  diagnosis  and  treatment. 

A  specially  sensitive  tooth  is  one  whose  tissues  are  in  an 
irritable  condition,   and  this  is  either  the  initial  step  in,   or  a 


I06  ORAL   PATHOLOGY   AND    PRACTICE, 

positive  stage  of,  an  active  inflammation.     The  irritant  may  be 

any  one  of  a  long  list,  and  may  have  its  origin  either  in  some 
organic  change,  in  a  mechanical  injury,  or  in  some  pathological  or 
diseased  condition.     Thus : 

1.  Caries  has  perhaps  invaded  the  tooth,  and  micro-organisms 
have  penetrated  the  tuhuli,  becoming  themselves  the  irritant,  or 
exposing  the  deeper  dentine  and  pulp  to  the  irritating  action  and 
thermal  changes  of  external  agents. 

2.  It  may  he  that  an  inserted  filling  is  this  outward  irritant. 

J.  There  may  be  recession  of  the  protecting  gum  tissue  at  the 
cervical  portion  of  the  tooth. 

4.  A  traumatic  injury,  a  blozv,  inordinate  use,  the  attrition  of 
mastication,  or  any  mechanical  violence  may  be  the  source. 

5.  Structural  changes  within  the  tooth  pulp,  such  as  the  forma- 
tion of  calcific  deposits,  are  a  sufficient  excitant. 

Whatever  the  possible  cause,  there  will  be  a  hyperemia  or 
determination  of  blood  to  the  irritated  pulp  tissue  and  an  engorge- 
ment of  its  capillaries.  Because  of  the  absence  of  the  usual  arterial 
and  venous  coats,  the  blood  channels  at  once  yield  to  the  pressure. 
There  is  not  the  normal  vaso-motor  system  of  nerves  to  control 
the  resilience  of  the  vascular  system,  and  diapedesis,  or  the  escape 
of  the  elements  of  the  blood  into  the  pulp  tissue,  is  materially 
modified.  It  may  not  at  once  take  place  in  the  usual  acceptance 
of  the  term,  but  a  stage  of  active  engorgement  of  the  blood 
channels  ensues.      (See  Fig.  26.) 

The  dental  pulp  is  without  the  full  and  complete  chain  of 
lymphatics  of  the  absorbent  system,  because  the  modification  of  the 
blood  supply  in  a  measure  makes  it  unnecessary.  The  compara- 
tively unrestrained  yielding  of  the  blood  channels,  and  the  retarda- 
tion of  the  infiltration  of  the  pulp  tissue,  allow  for  a  return  to  a 
physiological  state,  if  once  the  irritation  ceases,  without  the  ne- 
cessity for  the  usual  process  of  resolution  through  the  activity  of 
the  lymphatics  in  relieving  a  hyperplastic  condition.  It  follows, 
then,  that  the  treatment  of  ordinary  pulpitis,  after  the  removal  of 
the  irritating  cause,  should  be  directed  toward  the  relief  of  the 
congested  condition,  by  deflecting  in  some  manner  the  determin- 
ing blood  current  and  allowing  the  engorged  vessels  to  empty 
themselves.  So  long  as  the  possibility  for  this  exists,  it  is  quite 
feasible  to  preserve  the  vitality  of  an  inflamed  pulp. 


TREATMENT   OF    INFLAMED   DENTAL    PULP.  lOJ 

When  the  pathological  condition  shall  have  proceeded  to  the 
extravasation  into  the  body  of  the  tissue  of  inflammatory  products, 
there  are  practically  no  lymphatics  to  take  them  up,  and  their  re- 
moval is  as  impossible  as  is  that  of  any  great  effusion  in  the  brain. 
Pulp  capping  under  such  circumstances  will  be  a  hopeless  proceed- 
ing, and  the  presence  of  any  infiltrated  or  effused  matter  will  contra- 
indicate  it.  The  fact  that  some  pulps  become  fully  exposed  and 
their  investing  tooth  walls  are  broken  down  without  either  pain  or 
special  sensitiveness,  may  be  accounted  for  through  their  never 
taking  upon  themselves  real  inflammatory  conditions,  because  of  a 
modification  of  nerve  structure  greater  than  that  which  is  usual. 


CHAPTER  XXV. 


TREATMENT    OF    INFLAMMATORY    CONDITIONS    OF   THE 
DENTAL  PULP. 

Usually,  the  first  indication  of  irritation  of  the  dental  pulp 
is  responsiveness  to  external  impressions,  manifested  by  a  sensi- 
tiveness to  thermal  changes.  Cold  air  or  cold  water  cause  pain  of  a 
sharp,  lancinating  character.  Not  infrequently  the  neck  of  the 
tooth,  or  any  abraded  surface,  is  also  sensitive  to  an  outward  irri- 
tant, such  as  a  metal  tooth-pick  or  instrument.  This  indicates 
dentinal  irritation.  The  responsiveness  to  thermal  changes  in- 
creases and  becomes  more  persistent,  until  there  is  a  distinct 
odontalgia  or  toothache.  This  pain  will  be  rather  paroxysmal, 
returning  upon  slight  provocation  and  passing  away  in  a  few 
moments.  It  may  be  difificult  for  the  patient  to  determine  exactly 
which  tooth  is  affected,  because  of  its  sympathetic  nature  and 
because  it  is  distributed  over  a  considerable  territory.  Suc- 
cessively isolating  each  tooth  by  the  rubber-dam,  and  the  applica- 
tion of  alternate  heat  and  cold,  will,  however,  usually  determine 
the  matter.  Sometimes  there  is  a  response  to  percussion,  and  a 
diagnosis  may  thus  be  reached.  This  earlier  stage  will  be  that 
of  hyperemia,  and  the  beginning  of  engorgement,  or  congestion. 
The  exalted  sensibility  is  due  to  the  irritable  condition  of  the 
nerve  tissue.  If  relief  is  not  obtained,  the  pain,  with  the  exacerba- 
tion of  the  inflammatory  condition,  becomes  more  intense  and 
continuous.     With  the  increased  engorgement,  the  pulp,  which  is 


I08  ORAL    PATHOLOGY   AND    PRACTICE. 

lield  immovably  within  the  bony  tooth  walls,  becomes  intensely 
irritable,  and  the  pain  instead  of  continuing  remittent  becomes 
almost  continuous.  The  lancinating  flashes  can  no  longer  be  dis- 
-tinguished,  but  are  so  quick  in  succession  as  to  be  practically  unin- 
termittent,  and  there  is  at  the  same  time  a  deep,  boring  pressure 
felt,  which  indicates  that  the  inflammation  is  passing  or  already  has 
passed  to  its  second  stage,  that  of  effusion,  in  which  there  is  an 
•oozing  out  of  the  elements  of  the  blood  into  the  tissues. 

Up  to  this  point  the  vitality  of  the  pulp  may  readily  be  pre- 
served, if  active  measures  are  taken  for  the  relief  of  the  inflam- 
matory condition.  This  stage  once  passed,  and  extravasation  into 
the  pulp  tissue  having  taken  place,  the  probabilities  are  largely 
against  conservation. 

About  this  time  the  pain  changes  in  character  somewhat,  and 
it  is  not  of  such  a  sharp,  lancinating  nature.  It  becomes  more 
steady  and  less  paroxysmal.  There  is  a  greater  feeling  of  pres- 
sure, and  it  is  more  readily  located.  The  pulsation,  which  up  to 
'this  time  is  very  distinct,  now  ceases.  The  congestion  soon  reaches 
its  height,  and  entire  stasis  of  the  blood  current  in  the  pulp  is  immi- 
nent. Cold  is  no  longer  irritative  and  warmth  grateful.  The 
opposite  condition  ensues,  and  ice-water  will  relieve  the  pain,  while 
any  warm  application  exacerbates  it.  The  suffering  caused  by  the 
affected  organ  is  intense,  but  the  end  is  probably  near  at  hand. 
With  complete  stasis  sensation  is  gradually  lost,  the  pain  pro- 
gressively abates,  neither  cold  nor  heat  aggravates,  and  the  tooth 
is  irresponsive  to  any  ordinary  irritant.  The  inflammatory  process 
has  run  its  destructive  course,  and  the  pulp  is  dead.  This  is  the 
usual  train  of  symptoms  and  the  ordinary  progress  of  the  disease. 

The  treatment  in  the  earlier  stages  should  be  abortive.  Every 
effort  should  be  put  forth  to  relieve  the  hyperemic  condition  and  to 
restore  a  normal  circulation.  The  first  essential  is  to  make  a  clear 
diagnosis  of  the  case,  by  carefully  considering  all  the  symptoms. 
The  exact  stage  of  the  disease  should  be  determined  if  possible. 
This  having  been  done,  the  next  point  will  be  to  remove  the  cause. 
If  it  is  progressive  caries,  the  cavity  of  decay  should  be  carefully 
washed  out,  all  debris  removed,  and  an  anodyne  introduced.  If 
any  foreign  substance  is  the  irritant,  it  must  at  once  be  eliminated. 
The  tooth  must  be  relieved  of  all  labor  of  mastication  and  given 
■entire  rest.     Counter-irritants,  such  as  iodine  and  aconite,  or  capsi- 


TREATMENT    OF    INFLAMED    DENTAL    PULP.  I09- 

cum  bags  and  plasters,  are  useful  by  promoting  metastasis ;  that  is, 
a  new  focus  of  inflammation  is  created  in  an  approximate  territory, 
but  which  is  upon  the  surface  where  it  can  be  reached  and  where 
resolution  may  be  anticipated.  This  has  a  tendency  to  divert  the 
impending  blood  currents,  and  thus  to  relieve  the  threatened  en- 
gorgement of  the  pulp. 

Hot  pediluvia,  or  foot-baths,  should  be  prescribed,  preferably  to 
be  used  at  night  before  retiring.  The  water  must  be  as  hot  as  can 
well  be  borne,  and  these  are  to  be  continued  for  at  least  thirty 
minutes,  for  the  purpose  of  equalizing  the  circulation  and  relieving- 
the  plethoric  condition  of  the  pulp. 

Saline  cathartics  are  useful  and  may  frequently  be  employed 
with  good  results.  They  reduce  the  blood  tension,  remove  from  the 
sanguinary  fluid  a  portion  of  its  watery  constituent,  and  thus  greatly 
diminish  the  stress. 

Diaphoretics  are  perhaps  the  most  important  of  the  general 
remedies.  They  not  only  extract  a  considerable  amount  of  water 
from  the  system  and  from  the  blood  current,  but  they  act  as  general 
depurators,  promoting  healthy  functional  action  and  removing 
local  obstructions. 

Anodynes  are  indicated  and  should  especially  be  administered  to 
nervous  or  irritable  patients.  They  equalize  nervous  function  and 
tend  to  restore  the  proper  tone  to  the  arteries  and  veins  through 
the  vaso-motor  system,  and  to  allay  the  general  nervous  excitability. 

Probably  there  never  WcLS  a  case  of  simple  pulpitis  that  would 
not  yield,  temporarily  at  least,  to  the  vesicant  action  of  a  powerful 
counter-irritant  at  the  back  of  the  neck,  a  foot-bath  continued  for 
thirty  minutes,  and  twenty  to  forty  grains  of  potassium  bromide. 
Such  drastic  measures,  however,  are  not  often  called  for,  and  are 
inadvisable  when  milder  means  will  suffice. 

Any  of  the  preceding  measures  may  be  resorted  to  in  cases 
in  which  there  is  no  actual  or  threatened  exposure  of  the  pulp 
through,  progressive  caries,  or  by  accident.  When  there  is  a  large 
cavity  of  decay,  it  must  first  of  all  be  thoroughly  opened  up,  and 
all  debris  and  foreign  substances  removed  as  carefully  and  as 
completely  as  possible.  It  should  next  be  washed  out  with  tepid 
water  in  which  a  little  salt  has  been  dissolved,  by  gently  injecting- 
the  stream  from  a  mouth  syringe.  The  cavity  should  be  dried  out, 
and  a  pledget  of  cotton  dipped  in  oil  of  cloves,  or  dilute  creosote,. 


no  ORAL    PATHOLOGY   AND    PRACTICE. 

•or  hamamelis  inserted,  this  to  be  carefully  sealed  up  without  pres- 
sure, by  means  of  gutta-percha  or  a  pledget  of  cotton  dipped  in 
chloro-percha,  A  solution  of  sandarac  in  which  to  dip  the  cotton 
should  not  be  employed,  because  it  insecurely  seals  it  and  very  soon 
■decomposes,  leaving  the  cavity  in  a  worse  state  than  at  first.  It  is 
also  likely  to  encapsule  the  remedy,  and  thus  to  isolate  it  and 
preclude  its  action. 

If  there  is  actual  exposure  of  the  pulp  tissue,  after  the  cavity 
of  decay  has  been  opened  up  and  carefully  cleaned  and  washed 
out,  the  rubber-dam  should  be  applied,  the  opening  dried  out  by 
means  of  hot  air,  and  the  pulp  and  cavity  walls  sterilized  by  the 
application  of  mercuric  chloride,  solution  i  to  2000,  or  some  other 
effective  germicide.  If  there  is  considerable  congestion,  a  pledget 
of  cotton  dipped  in  the  following  may  be  carefully  placed  over 
the  point  of  exposure  and  sealed  up: 

■    1^ — Plumbi  acetatis,  gr.  v; 

Tinct.  opii,  3ss; 

Aquae,  oij. 

This  should  be  allowed  to  remain  for  some  hours,  when  it  may 
he  changed  for  a  dressing  of  dilute  oil  of  cloves,  or  of  cassia.  All 
pain  will  usually  cease  with  the  application  of  an  anodyne.  When 
more  active  measures  are  demanded,  the  following  dressing  may 
be  applied  after  the  sterilization: 

B — Atropinas  sulph.,  gr.  j ; 

Aquas  dest.,  "      8j. 

If  the  pulp  shall  have  been  wounded  and  bleeding  ensue,  or 
if  there  is  exudation  of  serum  from  the  exposed  pulp,  it  may  be 
dressed  with  a  solution  of  tinct.  iodine  and  persulphate  of  iron 
in  equal  parts.  Tinct.  opii  may  sometimes  be  necessary  for  the 
purpose  of  soothing  the  disturbed  tissue.  The  inflammation  and 
congestion  once  relieved,  the  necessary  operative  measures  for  the 
further  preservation  of  the  tooth  may  be  instituted.  If  there  is 
no  actual  pulp  exposure  these  may,  if  skillfully  executed,  be  con- 
fidently relied  upon  to  serve  their  full  purpose.  If,  however,  any 
portion  of  the  pulp  tissue  is  really  uncovered,  the  prognosis  will 
not  be  as  favorable.  In  the  earlier  stages  of  inflammation,  before 
there  is  any  exudation  from  the  bloodvessels  of  the  pulp,  the 
iDest  results  may  be  predicted.  If  there  has  been  extravasation  of 
the  contents  of  the  blood  channels  into  the  body  of  the  pulp  absorp- 


PERICEMENTITIS.  Ill 

tion  cannot  be  expected,  owing  to  the  absence  of  lymphatics,  and 
breaking  down  of  the  tissue  or  death  of  the  pulp  will  result. 
The  successive  stages  in  degeneration  may  be  tabulated  thus : 

First  Stage.  Second  Stage  Thjrd  Stage.  Fourth  Stage. 

■Symptoms Sensitiveness.    Pain  (cold  ex-  Pain  (cold  Insensibility. 

acerbates).  relieves). 

■Condition Irritation.  Infiltration.  Inflammation.  Stasis. 

Pathology Hyperemia.       Diapedesis.  Congestion.  Death. 

Prognosis Good.  Doubtful.  Bad.  Hopeless. 

Stasis  and  death,  as  suggested  by  Dr.  J.  B.  Willmott,  may  in 
some  instances  be  partial  in  the  third  stage,  while  in  other 
cases  decomposition  may  have  commenced  in  circumscribed  areas 
and  the  change  in  the  symptomatology  may,  at  least  in  part,  be  due 
to  the  condensation  of  the  putrefactive  gases  under  the  reduction 
of  temperature. 

The  different  remedies  in  the  several  classes  that  will  prove 
best  adapted  to  dental  practice  may  be  summarized  as  follows : 

Food  Laxatives. — Green  and  dried  fruits,  cracked  wheat,  oat- 
meal, etc. 

Medicinal  Laxatives. — Seidlitz  powder,  castor  oil  (doses  for 
adults  of  4  to  8  drams,  and  for  children  i  to  3  drams),  lac.  sulphur 
(^  to  3  drams,  in  syrup  or  milk). 

Saline  Cathartics. — Epsom  salts  (2  to  8  drams  in  carbonated 
water),  citrate  of  magnesia  (dose  according  to  preparation). 

Diaphoretics. — Warmth  and  exercise,  warm  drinks.  Dover's 
powder  (5  grains,  repeated  if  necessary),  spirits  of  Minder erus 
(2  to  8  drams  every  two  to  four  hours),  sweet  spirits  of  nitre  (2  to 
4  drams  frequently). 

Diuretics. — Diluent  drinks,  mineral  waters,  beef  tea,  whey, 
gruel,  cream  of  tartar  ( i  to  4  drams  combined  with  ^  dram  biborate 
■of  soda),  borax  (20  to  40  grains). 

Anodynes. — Potassium  bromide  (5  to  20  grains),  sulphate  of 
morphin  (-^  to  ^  grain),  aromatic  spirits  of  ammonia  (10  to  60 
drops). 

CHAPTER  XXVI. 

PERICEMENTITIS— INFLAMMATION  OF  THE  PERIDENTAL 

MEMBRANE. 

Sometimes  this  affection  is  closely  connected  with  inflamma- 
tions of  the  dental  pulp,  and  it  may  be  derived  from  mere  con- 


112 


ORAL   PATHOLOGY   AND   PRACTICE. 

Fig.  27. 


Enamel. 


Cornua  of,  Pulp  , 

Dentine 
Fibrous  Gum  Tissue 


Aberrant  Bloodvessel. 


Nutrient  Artery. 


Enamel. 


Dentine. 

Pulp. 

Fibrous  Gum  Tissue. 
Periosteum. 

Cementum. 
Pericementum. 
Aberrant  Bloodvessel. 
Cementum. 


Nutrient  Artery. 

Bifurcation  or  Branching; 

of  Pulp. 
Lateral  Foramen. 


Principal  Foraminal 
Opening. 


Nutrition  of  the  Dental  Pericementum  and  Pulp. 

The  condition  here  represented  is  that  seen  only  in  young  persons.  In  later  life  the 
"  aberrant"  bloodvessels  and  some  of  the  canals  at  the  apex  may  be  closed  by  the  advancing 
calcification.  The  former  are  not  constant  but  sometimes  may  be  observed.  Cementum  is  a 
modification  of  bone,  and  these  vessels  may  have  a  genetic  relation  to  Haversian  canals.  The 
cut  is  schematic  and  not  according  to  scale. 


PERICEMENTITIS.  II 3 

tiguity  or  proximity  of  tissue.  Usually,  however,  it  arises  quite 
independent  of  the  other  disorder,  and  indeed  is  more  severe  when 
the  pulp  has  been  devitalized,  either  by  design  or  disease. 

The  pericementum  is  an  exceedingly  vascular  organ,  and  it 
has  an  abundant  nerve  supply.  This  is  necessary  to  its  proper 
functional  action.  It  is  a  kind  of  placental  organ  which  affords  the 
pulp  of  the  tooth  its  vascular  and  nervous  supply.  The  text-books 
and  preparations  which  represent  the  arteries  and  veins  of  the 
tooth  pulp  as  passing  out  at  a  single  foraminal  opening,  perforating 
the  pericementum  and  traversing  the  tissues  until  they  anastomose 
with  some  larger  vessel  of  which  they  are  branches,  and  which  is 
not  in  relation  with  the  tooth  at  all,  cannot  be  accepted  as  repre- 
sentative of  the  actual  condition.  No  bloodvessel  can  be  directly 
traced  beyond  the  investing  pericemental  membrane.    (See  Fig.  27.) 

Fig.  2$. 


Tooth  Extracted  by  Author  for  Replantation,  with  Minutf.  Threads  of  Chloro- 
PERCHA  Forced  through  Dentine  and  Cementum  in  Filling  the  Root. 

The  foraminal  opening  of  the  normal  tooth  root  is  not  a  single 
direct  aperture,  having  its  axis  in  line  with  that  of  the  pulp,  but, 
especially  in  early  life,  is  a  delta  with  a  number  of  communicating 
orifices,  which  begin  to  diverge  near  the  apical  junction  of  the 
dentine  and  cementum,  and  with  a  kind  of  circular  sweep  reach 
the  pericemental  membrane,  with  whose  bloodvessels  the  branches 
from  the  dental  pulp  anastomose.  Indeed,  in  early  life  the  ana- 
logues of  Haversian  canals  are  not  infrequently  found  penetrating 
the  cementum  and  dentine  at  different  points  along  the  periphery 
of  the  tooth  root,  and  containing  accessory  bloodvessels  for  the 
further  supply  of  the  pulp.  Later  in  life  these  are  usually  oblit- 
erated by  the  advancing  calcification.  That  this  is  true,  the  clin- 
ical observation  of  almost  any  dentist  of  wide  experience  might 
establish.     There  are  few  such  who  have  not  seen  the  whole  apex 

9 


114  ORAL    PATHOLOGY   AND    PRACTICE. 

of  a  tooth  root  denuded  through  some  pathological  process,  or  by 
surgical  operations,  without  interference  with  the  vitality  of  the 
pulp.  Many  have  known  instances  in  which,  through  diseased 
action  or  by  accident,  one  side  of  the  root  of  an  anterior  tooth, 
with  the  whole  of  the  apex,  was  completely  denuded  without  any 
devitalization  of  the  pulp.  When  this  tissue  has  been  restored  by 
functional  activity,  the  tooth  was  found  as  responsive  to  thermal 
changes  as  ever.  The  author  has  frequently  had  occasion  to 
remove  all  the  investing  osseous  tissue  from  a  tooth  root,  save 
perhaps  a  comparatively  small  portion  at  one  side,  and  that  without 
final  prejudice  to  its  vitality.     In  some  of  these  instances  there 

Fig.  29. 


Tooth  with  Hypertrophied  Pericementum  showing  Blood  Supply. 

Microscopical  section  demonstrated  that  nutrient  arteries  of  considerable  size  entered  at 
a  and  6  and  were  distributed  to  the  pericementum.  (From  a  specimen  furnished  the  author 
by  Dr.  D.  E.  Kulp.) 

could  have  been  no  vascular  supply  to  the  pulp,  unless  it  was 
through  some  kind  of  Haversian  canal  penetrating  the  cementum 
and  dentine  upon  a  lateral  aspect.  The  author  has  frequently 
demonstrated  the  presence  of  something  of  this  kind  in  freshly 
extracted  young  teeth.     (See  Fig.  28.) 

It  is  well  known  to  oral  surgeons  that  resection  of  the  inferior 
dental  canal,  with  entire  obliteration  of  the  inferior  dental  artery 
and  nerve,  does  not  in  any  way  interfere  with  the  vitality  of  the 
lower  teeth,  which  the  text-books  frequently  represent  as  receiving 
their  vascular  and  nervous  supply  from  that  source.  These  con- 
siderations should  materially  modify  our  views  of  the  pathology  of 
the  dental  pericementum,  and  change  some  previous  conceptions  of 


PERICEMENTITIS.  115 

its  function  and  susceptibility  to  diseased  action.  In  the  light  of 
these  views,  much  that  was  before  incomprehensible  becomes  plain 
and  intelligible.  We  can  understand  why  and  how  it  is  that  the 
blood  and  nerve  supply  of  the  tooth  is  modified,  and  how  it  arises 
that  the  vessels  of  both  are  without  the  usual  external  muscular 
coats,  and  approach  those  of  the  brain  in  character. 

Having  the  important  and  compound  functions  of  affording 
the  pulp  of  the  tooth  its  nerve  and  blood  supply  and  giving  nutri- 
tion to  the  cementum  and  bone,  and  being  in  close  relation  with 
the  gum  tissue,  the  pericementum  is  very  likely  to  take  upon  itself 
a  pathological  condition.  Continued  irritation  of  a  mild  character 
may  result  in  a  hyperplasia  of  the  membrane,  with  an  enlargement 
of  the  principal  nutrient  arteries  and  a  generally  congested  irrita- 
tive condition.  (See  Fig.  29.)  It  serves  as  a  cushion  to  break  the 
force  exerted  upon  the  tooth  in  occlusion,  or  from  a  blow,  or  any 
other  external  violence.  Hence  it  is  liable  to  injuries  and  acci- 
dents. It  is  also  very  subject  to  infection  by  micro-organisms 
from  a  decomposing  tooth  pulp.  This  last  is  without  doubt  the 
most  fruitful  source  of  inflammatory  conditions,  and  such  instances 
are  constantly  falling  under  the  notice  of  the  dentist  and  oral 
physician.  Another  common  cause  is  the  bad  occlusion  or  absence 
of  some  of  the  teeth,  which  throws  upon  a  few  the  work  of  many. 
Teeth  used  as  anchorages  for  bridges  of  an  extensive  kind  are 
peculiarly  liable  to  and  are  often  lost  by  pericemental  irritation 
caused  by  overwork. 

Many  practitioners  have  no  clear  conception  of  the  difference 
between  pericementitis  and  pulpitis,  inasmuch  as  each  produces 
a  distinct  odontalgia  or  toothache  which  only  close  observation 
will  distinguish  from  the  other.  And  yet  the  two  conditions  have 
little  in  common  except  the  pain,  and  that  is  not  of  the  same 
character.  It  may  be  well  to  compare  their  pronounced  symp- 
toms as  an  aid  in  diagnosis. 

Pulpitis.  Pericementitis. 

The  pain  is  of  a  sharp,  lancinating  The   pain  is   dull,    steady,   boring, 

character,  and  in  its  earlier  stages  it  throbbing  in  its  character,  and  is  not 

is  distinctly  paroxysmal.  at  all  paroxysmal. 

The  tooth  is  exquisitely  sensitive  There  is  no  sensation  to  changes  of 

to  thermal  changes;  in  its  inceptive  temperature,    and    neither    cold    nor 

state  cold,  and  in  its  later  condition  hot  applications  materially  affect  it, 
heat,  exacerbating  the  pain. 


Il6  ORAL    PATHOLOGY   AND   PRACTICE. 

Pulpitis  (cont.).  Pericementitis    (cont.). 

There  is  no  swelling  of  the  tissue  The  tooth  becomes  exceedingly 
about  the  tooth,  and  no  tenderness  to  sore,  and  the  least  pressure  upon  it 
pressure  in  ordinary  cases,  unless  the  causes  pain.  In  the  later  stages 
pulp  shall  in  some  way  be  exposed.         swelling  is  common. 

It  is  at  times  quite  difficult  to  de-  There  is  no  trouble  in  deciding 
termine  exactly  which  tooth  is  af-  which  tooth  is  the  diseased  one,  the 
fected,  the  pain  being  fleeting  in  its  pain  being  steady  in  degree  and  in 
nature,  and  inducing  reflex  symptoms  position,  and  the  soreness  readily 
in  other  teeth  and  tissues.  locating  it. 

The  pain  is  apt  to  be  worse  upon  The  pain  remains  nearly  constant 
going  to  bed,  and  excitement  and  without  much  reference  to  external 
fatigue  increase  it.  conditions  or  circumstances. 

It  is  possible  to  bite  upon  the  tooth  The  tooth  is  very  sore  to  the 
without  any  special  sensation,  and  to  touch,  any  occlusion  in  mastication 
use  it  in  mastication,  if  thermal  ex-  or  ordinary  shutting  of  the  mouth 
tremes  be  avoided.  giving  pain,  irrespective  of  thermal 

changes. 

The  tooth  is  not  elongated,  nor  The  tooth  is  raised  in  its  socket, 
does  it  strike  first  in  occlusion.  and  strikes  before  any  of  the  others 

occlude. 

Treatment  of  Pericementitis. 

The  first  care  should  be  to  give  the  offending  tooth  rest,  by 
preventing  its  occlusion.  This  may  be  done  by  placing  gutta- 
percha caps  over  other  teeth,  to  prevent  the  striking  of  this.  The 
cause  should  be  determined,  and  if  possible  removed.  If  it  be 
infection  from  a  dead  pulp,  the  chamber  should  be  carefully 
cleaned  and  sterilized,  and  an  anodyne  applied  in  the  root  channel, 
caution  being  exercised  to  avoid  forcing  septic  matter  through  the 
foraminal  openings.  It  may  be  advisable  to  seal  up  in  it  some  of 
the  essential  oils,  properly  diluted,  such  as  cassia  or  cloves,  as  an 
antiseptic.  A  counter-irritant  should  be  applied  over  the  apex  of 
the  affected  tooth,  for  the  same  reason  that  it  is  used  in  pulpitis, 
and  it  is  even  more  likely  to  be  effectual.  The  same  general 
remedies  may  be  employed,  such  as  saline  cathartics,  diaphoretics 
and  nervous  sedatives.  Refrigerants  are  useful,  and  lumps  of  ice 
wrapped  in  muslin  may  be  placed  between  the  lip  and  the  tooth. 

If  these  are  not  effectual,  resolution  may  sometimes  be  in- 
duced by  hot  fomentation  upon  the  face  and  neck.  Prof.  C.  N. 
Johnson  recommends  that  water  as  hot  as  can  be  borne  be  directed 
upon  the  part,  with  some  force,  for  twenty  or  thirty  minutes,  to 


ALVEOLAR   ABSCESS.  II/ 

promote  resolution.  An  acute  pericementitis  has  also  been 
readily  aborted  by  the  precisely  opposite  treatment  of  directing 
an  ether  or  rhigolene  spray  upon  the  part  until  it  has  become 
bloodless.  Both  are  useful,  but  are  best  adapted  to  different 
stages  of  the  disease.  If  infection  is  present  Prof.  A.  W.  Harlan 
recommends  the  administration  of  one-tenth  of  a  grain  of  calcium 
sulphide  every  ten  minutes  for  an  hour,  the  interval  then  to  be  grad- 
ually increased.  If  there  is  a  great  degree  of  pain,  the  following 
may  be  administered: 

3J — Acetanilid.,  gr.  viij ; 

Syr.  simp.,  3ij; 

Spts.  frumenti,  3ij. 

Sig. — One-half  at  6  p.m.,  the  remainder  two  hours  later. 

The  patient  should  be  given  a  hot  foot-bath,  placed  in  bed 
and  kept  warm.  If  the  inflammation  is  exceedingly  acute,  scari- 
fication of  the  gums  about  the  affected  tooth  may  be  resorted  to. 
If  there  is  great  tension  of  the  tissue,  a  sharp-pointed  scalpel  or 
bistoury  may  be  used  to  cut  through  the  gum  tissue  over  the 
apex  of  the  tooth,  a  little  cocain  having  been  previor\sly  applied, 
or  the  point  of  the  instrument  dipped  in  pure  carbolic  acid  and 
applied  to  the  surface  until  it  has  become  white,  when  it  may  be 
forced  through  the  alveolar  walls  until  the  seat  of  inflammation 
is  reached,  thus  removing  the  tension  and  giving  immediate  relief. 


CHAPTER  XXVII. 
ALVEOLAR  ABSCESS. 
An  Abscess  is  the  formation  of  pus  somewhere  within  the  body, 
as  the  result  of  some  local  or  circumscribed  inflammation.  An 
Alveolar  Abscess  is  an  infective  inflammation  within  the  alveolar 
walls.  It  may  be  the  result  of  some  foreign  substance  acting  as 
an  irritant,  or  some  injury  may  have  been  the  exciting  cause. 
Either  of  these  agencies  may  result  in  an  inflammation  so  violent 
as  to  induce  a  breaking  down  of  tissue,  and  infection  with  sup- 
purative organisms  will  induce  the  formation  of  pus,  which 
reaches  the  surface  by  the  route  presenting  the  least  resistance. 
An  alveolar  abscess  does  not,  therefore,  necessarily  presuppose  the 
death  of  the  pulp.     If  the  inflammation  does  not  materially  affect 


Il8  ORAL    PATHOLOGY   AND    PRACTICE. 

that  tissue,  or  if  the  pericementum  involved  does  not  include  that 
from  which  the  blood  supply  of  the  tooth  is  derived,  an  alveolar 
abscess  may  be  established  without  pulp  devitalization. 

The  terms  "abscess"  and  "ulcer"  are  frequently  confounded. 
Even  dentists  of  intelligence  speak  of  an  "ulcerated  tooth,"  when 
practically  such  a  thing  is  an  absurdity.  An  abscess  and  an  ulcer 
have  little  in  common.  The  primary  cause  of  the  first  is  infection 
by  some  pyogenic  organism,  which  necessarily  has  no  part  in  in- 
ducing an  ulcer.  An  abscess  always  forms  in  some  cavity  within 
the  body :  an  ulcer  always  has  its  inception  on  an  external  cutaneous 
surface.     An  abscess  is  a  circumscribed  collection  of  pus :  that  is 

Fig.  30. 


Pericemental  Abscess  which  in  No  Way  Involves  the  Vitality  of  the 
Tooth  Pulp.    (E.  C.  Kirk.) 

not  at  all  true  of  an  ulcer.  The  one  makes  progress  from  within 
outward :  the  other  just  the  reverse.  The  one  tends  toward  resolu- 
tion :  the  other  is  progressively  degenerative.  An  abscess  is  always 
the  result  of  a  recent  lesion  :  an  ulcer  is  never  connected  with  a  fresh 
wound  or  infection,  but  has  its  inception  in  some  old  injury  or 
morbid  structural  change.  It  would  be  difhcult  to  instance  a 
grosser  misuse  of  technical  terms  than  the  calling  of  an  alveolar 
abscess  an  "ulcerated  tooth." 

Professor  Kirk  has  demonstrated  that  a  pericemental  abscess 
may  develop  in  the  parenchyma  of  the  membrane ;  that  is,  it  may  be 


ALVEOLAR    AUSCLSS. 


119 


neither  supra-  nor  infra-,  but  intra-pericemental.  (See  Figs.  30 
and  31.)  It  is  indeed  probable  that  such  aljscesses  are  more  fre- 
quent than  is  usually  supposed.  Most  practitioners  of  experience 
have  at  some  time  in  their  lives  drilled  into  an  abscessed  tooth  and 
found  a  living  pulp,  which  would  demonstrate  that  the  lesion  was 
not  at  the  foraminal  apex.     By  the  study  of  these  conditions  Pro- 

FiG.  31. 


Transverse  Section  across  Buccal  Roots  of  Fig.  30,  showing    the  Abscess-cavity 

TO   BE   between   THE   PERICEMENTAL   WALLS. 

a,  a.  Hypercementosis.  d.  Thickened  pericementum  covering  root.  d^.  Thickened  peri- 
cementum forming  e.xternal  wall  of  abscess-cavity,  c.  Abscess-cavity  occupying  centra!  por- 
tion of  divided  pericemental  membrane,    d.  Section  through  fistulous  outlet  of  abscess.     (Kirk.) 

fessor  Kirk  believes  he  has  found  a  common  factor  of  infection  to 
be  the  diplococcus  of  pneumonia,  or  the  pneumococcus  of  Fried- 
lander,  with  occasionally  staphylococcus  pyogenes  aureus  as  a  con- 
comitant. 


I20 


ORAL   PATHOLOGY   AND   PRACTICE. 


But  such  a  condition  is  not  that  which  has  usually  been  denomi- 
nated alveolar  abscess.  The  common  acceptation  of  the  term  is  that 
affection  which  is  the  result  of  inflammation  and  death  of  the 
pulp,  its  infection,  and  the  consequent  inflammation  and  infection 
of  the  pericementum  from  contiguity  of  tissue.  If  we  take  up 
the  subject  of  the  last  chapter  at  the  point  of  its  closure,  and 
suppose  the  pulp  of  a  tooth  to  be  devitalized  as  the  result  of  stasis 
of  the  blood  currents,  with  the  consequent  stoppage  of  all  nutrition 
through  a  distinctive  inflammation,  the  next  inquiry  will  be 
concerning  the  final  disposition  of  the  devitalized  pulp. 

Fig.  32. 


^-^^■'^,^^T^m)^* 


-''^*%»/, 


Metastatic  Abscess. 


Mass  of  staphylococci  in  the  center,  surrounded  by  an  area  of  coagulation  necrosis,  the 
whole  inclosed  by  a  cordon  of  leucocytes.     (Kirk.) 

If  there  is  no  source  through  which  it  can  becorne  infected 
with  micro-organisms,  it  will  probably  become  mummified  and 
desiccated;  the  moisture  will  be  absorbed  from  it,  and  it  will 
assume  the  condition  of  dry  gangrene,  in  which  it  will  remain  for 
an  indefinite  period  without  being  the  cause  of  any  irritation  what- 
ever. 

If,  however,  such  a  pulp  chamber  be  opened  without  the 
strictest  antiseptic  precautions,  perhaps  years  after  the  death  of 


ALVEOLAR    ABSCESS.  121 

its  contents,  germs  of  infection  may  be  carried  in  upon  the  non- 
sterilized  instruments  or  admitted  with  a  particle  of  saliva,  and 
.septic  inflammation,  with  perhaps  consequent  alvoolar  abscess,  will 
be  the  result. 

The  infection  may  arise  from  either  one  of  two  sources.  If 
there  is  a  cavity  in  the  tooth  that  penetrates  to  the  neighborhood 
■of  the  pulp,  the  bacteria  may  there  find  entrance,  and  decomposing 
the  pulp  tissue  by  putrefaction  they  may  cause  the  formation  of 
offensive  gases,  which  forcing  their  way  through  the  foraminal 
•openings  will  act  as  an  irritant  upon  the  pericementum,  and 
induce  an  acute  inflammation  of  that  tissue. 

Fig.  33. 


Blind  Abscess  at  the  Root  of  an  Upper  Incisok. 
a,  Abscess  cavity  in  the  bone.    6,  Drill  hole  exposing  the  pulp  chamber  for  drainage. 
'(Burchard,  after  Black.) 

If  there  is  no  special  cavity  of  decay  in  the  tooth  containing 
the  recently  devitalized  pulp  through  which  infective  organisms 
may  find  entrance,  it  may  still  become  contaminated  from  some 
other  center  of  infection  that  may  exist  in  the  body.  The  bacteria 
may  be  transported  by  the  blood  or  through  the  lymph  tracts,  or 
may  in  some  other  manner  be  carried  within  the  body  to  the  dead 
tissue,  and  in  this  manner  form  a  source  of  contagion.  By  what- 
ever method  the  pulp  becomes  inoculated  with  putrefactive  or  sup- 
purative organisms,  whether  from  external  sources  or  by  auto- 
infection,  the  result  will  be  the  same, — the  formation  of  suppurative 
products  and  the  infection  of  the  pericementum  and  other  tissues 
in  the  neighborhood  of  the  foraminal  openings.  Pus  will  thus  be 
formed  and  an  abscess  established  (see  Fig.  33). 

Incipient  Alveolar  Abscess  is  the  term  applied  to  the  condition 


122  ORAL    PATHOLOGY    AND    PRACTICE. 

that  has  existed  up  to  this  point.  It  simply  implies  the  earlier 
stages  of  the  destructive  inflammation,  before  pus  shall  be  actually 
present,  during  which  period  it  may  be  possible  to  abort  the  abscess^ 
or  prevent  the  breaking  down  of  tissue. 

A  Blind  Abscess  is  one  in  which  the^'e  is  a  cavity  of  decay  com- 
municating with  the  pulp  chamber,  and  in  which  it  is  possible  for  the 
pus  to  be  drained  through  the  pulp  canal. 

A  Discharging  Abscess  is  that  condition  in  which  the  pus  forces 
its  way  to  the  surface  through  the  alveolar  zvalls  and  establishes  a 
fistulous  opening. 

The  formation  of  an  alveolar  abscess  depends  upon  infection 
by  septic  organisms.     These  are  always  a  source  of  irritation,  and' 

Fig.  34. 


Infected  Exudate  about  the  Apices  of  the  Roots  of  a  Molar  Tooth  in  a  Case  of 
Subacute  Pericementitis. 

The  center  of  the  mass  consists  of  pus  and  broken-down  tissue  ;  the  superficial  portion  is 
the  desiccated  exudate  not  yet  decomposed. 

induce  inflammatory  conditions.  The  pericementum  about  the 
foraminal  opening  of  the  root  of  a  tooth  being  thus  affected,  there 
will  ensue  under  the  stress  of  the  inflammatory  conditions  the 
phenomena  described  in  the  chapter  (VI.)  on  General  Inflamma- 
tion. There  will  be  changes  in  the  bloodvessels  of  the  vascular 
tissues  that  will  finally  result  in  diapedesis,  or  the  pouring  out  of  the 
plastic  lymph.  This  will  be  infected  by  the  organisms,  and  in- 
stead of  being  either  removed  by  resolution  or  built  up  by  regular 
progressive  metamorphosis,  it  will  be  broken  down.  The  leuco- 
cytes, or  white  blood  corpuscles  that  have  thronged  to  the  irritated 
neighborhood,  will  lose  their  vitality  through  the  irritation  and 
infection,  and  assume  the  character  of  pus  corpuscles;  the  invest- 
ing tissue  will  be  broken  down  and  decomposed,  thus  forming  a 


ALVEOLAR    ABSCRSS.  1 23. 

cavity  about  the  foraminal  opening;  the  water  of  the  tissue  and 
the  serum  of  the  blood  will  mingle  with  these,  and  the  whole  mass 
will  be  that  fluid  that  forms  the  contents  of  the  abscess  cavity. 

If,  now,  an  opening  be  drilled  to  the  pulp  chamber  this  septic 
matter  may  be  discharged  through  the  pulp  canal  and  a  blind 
abscess  will  be  the  result.  (See  Fig.  33.)  If  there  is  no  surgical 
interference  the  pus  will  make  its  own  way  to  the  surface  by  the 
line  of  least  resistance,  and  there  form  a  fistulous  opening. 

There  may  be  about  the  periphery  of  this  pus  cavity,  V7hen  so 
formed  through  the  breaking  down  of  the  tissue,  a  partial  attempt 
on  the  part  of  nature  to  build  the  exudate  into  new  tissue.  It  may 
possess  a  kind  of  consistence,  and  this  partially  organized,  partially 
desiccated  plastic  lymph  will  form  a  line  of  demarkation  that  will 
inclose  the  disturbed  territory.  (See  Fig.  34.)  Upon  its  external 
surface  it  will  exhibit  the  characteristics  described,  but  its  center 
will  be  a  collection  of  pus  and  disorganized  lymph.  If  the  tooth 
is  now  extracted,  this  mass  may  be  found  clinging  to  the  root,  the 
size  of  an  ordinary  pea,  and  when  so  removed  with  a  deciduous 
tooth  it  has  been  mistaken  by  the  unintelligent  for  the  germ  of  a 
permanent  tooth.  It  is  only  the  plastic  exudate  that  filled  the  cavity 
produced  by  the  breaking  down  of  the  tissue,  whose  surface  is 
desiccated  or  dried,  while  its  interior  is  completely  broken  down. 

The  infected  point  may  not  be  at  the  foraminal  apex  of  the 
tooth,  but  may  be  at  some  point  upon  the  side  of  the  root,  or  between 
them  at  their  point  of  divergence. 

The  fact  that  the  blood  and  nerve  supply  of  the  dental  pulp- 
are  derived  from  the  pericementum,  and  that  channels  analogous' 
to  the  Haversian  canals  of  bone  may  in  comparatively  young 
persons  communicate  with  the  pulp  through  the  cementum  and 
dentine  at  almost  any  point,  naturally  introduces  another  complica- 
tion in  the  proper  treatment  of  so-called  dead  teeth.  Not  infre- 
quently is  an  exceedingly  sensitive  point  found  somewhere  along 
its  course  when  a  broach  is  passed  into  the  pulp  canal  of  a  devital- 
ized tooth,  and  it  may  be  that  the  oozing  of  blood  and  serum' 
from  such  a  point,  even  after  the  foramen  has  been  stopped,  will' 
give  great  annoyance.  This  may  be  the  mouth  of  one  of  these 
communicating  blood  channels,  and  it  is  easy  to  comprehend  that 
the  pericementum  at  the  point  at  which  this  is  given  off  may 
readily  become  infected  from  a  septic  canal,  and  thus  form  a  focus- 


124 


ORAL    PATHOLOGY   AND    PRACTICE. 


■of  inflammation  and  disorganization  quite  distinct  from  that  about 
the  usual  foraminal  opening.  The  latter  may  be  thoroughly 
drained  and  completely  sterilized  without  beneficial  result,  because 
it  is  reinfected  from  another  opening  in  the  pulp  canal  as  fast  as 
it  is  rendered  aseptic.  In  teeth  having  more  than  one  root  these 
■collateral  vascular  branches  are  sometimes  given  off  from  the  peri- 
cementum at  the  bifurcation,  and  at  these  points  may  be  established 
a  focus  of  infection  and  inflammation  which  it  is  difficult  thor- 
oughly to  drain,  and  impossible  entirely  to  disinfect  and  sterilize. 

Pus  having  once  formed  at  any  point  about  the  periphery  of 
a  tooth,  it  becomes  necessary  for  it  to  be  evacuated,  as  it  is  essen- 
tially a  foreign  body  possessing  peculiarly  irritating  properties. 


Alveolar  Abscess  at  the  Root  of  a  Superior  Incisor  Discharging  into  the 
Anterior  Nasal  Fossa. 

a,   Very  large  abscess  cavity  in  the  bone,    b.  Fistulous  opening  in  the  nasal   cavity,    c, 
Lip.    d,  Tooth.     (Black.) 

It  usually  secures  egress  through  the  breaking  down  of  the  tissue 
that  encompasses  it.  The  pressure  of  the  gases  of  putrefaction  that 
are  evolved,  with  that  of  the  constantly  increasing  pus,  causes 
resorption  of  the  investing  bone,  while  the  inflammation  and 
infection  induce  progressive  decomposition,  and  thus  an  opening 
is  made  to  the  surface,  the  pus  is  evacuated  and  the  acute  symp- 
toms pass  away. 

If  no  remedial  measures  are  instituted,  the  sinus  perhaps  then 
■closes  up  and  the  patient  may  fancy  that  a  cure  is  established. 
But  the  pericementum  at  the  infected  point,  and  the  tissues  about 
it  immediately  involved,  remain  in  a  septic  condition,  and  the 


-ALVEOLAR   ABSCESS. 


125 


efforts  of  nature  to  restore  a  true  physiological  condition  are  made 
futile  by  constant  reinfection.  An  acute  inflammatory  stage 
again  ensues,  the  plastic  exudate  is  once  more  poured  out,  only 
to  be  reinfected,  with  a  fresh  breaking  down  into  pus.  The 
abscess  "gathers"  again,  but  this  time,  as  the  old  sinus  will  not 
have  been  completely  obliterated,  there  will  be  less  resistance,  and 
the  pus  will  with  decreased  difficulty  reach  the  surface.  This 
process  may  be  periodically  repeated  until  a  complete  and  con- 

FlG.  36. 


Chronic  Alveolar  Abscess  with  Fistula  Discharging  under  the  Chin. 

The  pus  burrows  through  the  soft  tissue  beneath  the  periosteum  until  it  reaches  the  point 
of  exit,  a,  Abscess  cavity  in  the  bone,  b,  b,  b.  Course  of  fistula,  c,  Lower  lip.  d,  [Inferior 
incisor.    (Black.) 

tinually  patulous  sinus  shall  have  been  formed,  when  all  acute 
symptoms  disappear  and  a  chronic  abscess  is  established,  through 
the  disorganization  of  the  nutritive  currents  and  the  continuous 
effusion  and  uninterrupted  infection  and  breaking  down  that  ensue. 
This  condition  may  persist  until  a  cavity  of  considerable  extent 
has  been  formed  in  the  alveolus,  or  even  in  the  body  of  the  bone. 
The  course  of  the  pus  in  reaching  the  surface  in  the  usual 


126 


ORAL    PATHOLOGY    AND    PRACTICE. 


forms  of  alveolar  abscess  is  directly  through  the  thin  alveolar  walls. 

This  is  the  shortest  route,  and  the  one  that  ordinarily  presents  the 
least  resistance.  But  although  the  tendency  of  the  pus  is  toward 
the  nearest  point  of  exit,  the  external  plates  of  the  bone  are  usually 
compact  tissue,  while  the  interior  is  cancellous.  Because  of  this 
fact  the  burrowing  may  be  through  the  less  dense  portions  of  the 
bone  and  away  from  the  usual  course. 


Separation  of  the  Periosteum  from  the  Bone  by  the  Burrowing  of  Pus  from 

AN  Alveolar  Abscess. 
a,  Abscess.   5,  Pus  pocket  beneath  periosteum,  c,  Lower  lip.  rf,  An  inferior  tooth.  «,  Tongue. 
(Burchard,  after  Black.) 

The  pus  may  find  some  cavity  of  the  body  and  be  discharged 
into  the  posterior  or  anterior  nares,  or  into  the  maxillary  sinus. 

In  such  instances  the  diagnosis  may  be  extremely  difficult.  Many 
•cases  are  on  record  in  which  treatment  had  for  a  long  time  without 
avail  been  directed  toward  complications  which  did  not  exist  in 
reality  until  a  more  careful  examination  revealed  a  dead  tooth  as 
the  source  of  all  the  trouble.     (See  Fig.  35.) 

Sometimes  the  pus  will  penetrate  the  alveolar  walls,  and,  en- 
countering the  fascia  of  a  muscle,  follow  along  its  course  until  it 


ALVEOLAR   ABSCESS.  127 

reaches  a  point  considerably  distant  before  it  finally  finds  the  sur- 
face. A  discharging  abscess  under  the  chin,  the  direct  result  of  a 
devitalized  inferior  incisor  tooth,  has  often  puzzled  the  medical 
man,  who  never  once  thought  that  the  dentist  might  give  quick 
relief.  (See  Fig.  36.)  Pus  has  been  known  to  burrow  along  the 
fibers  of  the  platysma  myoides  muscles  until  it  has  reached  the  clavi- 
cle, or,  penetrating  the  cervical  fascia,  finally  strike  the  omo-hyoid 
and  follow  its  course  until  it  emerged  at  the  point  of  the  scapula. 

In  some  instances  of  rather  indolent  abscess,  the  pus  makes  its 
way  through  the  alveolar  walls  until  it  reaches  the  periosteum  of 
the  bone,  which  it  detaches,  and  spreading  out  beneath  it  completely 
cuts  off  all  periosteal  nutrition.  (See  Fig.  37.)  This  is  a  condition 
v/hich,  if  not  relieved,  may  result  in  osseous  necrosis.     It  may  be 

Fig.  38. 


Alveolar  Abscess. 

a.  Primary  abscess  pocket,    b,  Secondary  pocket  caused  by  the  infiltration  of  septic  matter 
through  the  cancellous  bone  tissue. 

observed  more  frequently  in  the  vault  of  the  mouth,  when  the  pus 
has  penetrated  the  palatal  process  of  the  superior  maxillary.  The 
tough,  fibrous  character  of  the  tissue  immediately  beneath  the 
mucous  membrane  of  the  roof  of  the  oral  cavity  presenting  a  great 
obstacle  to  the  course  of  the  pus,  it  not  infrequently  spreads  over 
a  considerable  portion  of  one  side  of  the  vault. 

There  are  cases  in  which  the  pus  burrows  to  some  distance  in 
the  alveolus,  establishing  separate  pockets  which  become  distinct 
points  of  infection.  (See  Fig.  38.)  In  one  such  instance,  from  an 
infected  point  at  the  apex  of  a  superior  cuspid,  which  had  a  dis- 
charging sinus  between  that  and  the  point  of  the  lateral  incisor,  and 


128  ORAL    PATHOLOGY   AND    PRACTICE. 

which  persistent  treatment  failed  to  cure,  a  secondary  sinus  was- 
finally  traced  back  to  a  point  between  the  first  and  second  premolars, 
or  bicuspids,  where  was  a  second  focus  of  infection,  and  from  this 
another  led  yet  farther,  back  of  the  roots  of  the  second  bicuspid, 
where  there  was  a  third  pus  chamber.  It  was  not  until  all  these 
were  explored  and  sterilized  that  anything  approaching  a  cure 
could  be  obtained. 

These  secondary  pockets,  or  foci  of  infection,  whether  upon 
the  periphery  of  the  tooth  as  the  result  of  a  former  collateral 
blood  supply  to  the  pulp,  or  existing  as  pockets  within  the  alveolus 
in  consequence  of  the  burrowing  of  pus  back  into  the  bone,  are 
especially  perplexing  to  the  practitioner,  because  he  never  knows 
when  to  expect  them,  and  he  has  no  early  means  of  diagnosing 
the  exact  location  of  the  seat  of  the  trouble.  After  the  proper  dis- 
infecting and  sterilizing  process  has  been  resorted  to  in  vain,  it 
may  be  suspected  that  there  are  somewhere  foci  of  infection  that 
have  not  yet  been  reached  by  the  remedies  used.  The  continuation 
of  the  discharge  oi  septic  or  sanious  matter  indicates  that  disinfec- 
tion and  antisepsis  are  not  complete,  and  no  entire  cure  may,  under 
such  conditions,  be  expected. 


CHAPTER  XXVIII. 


SYMPTOMATOLOGY  AND  TREATMENT  OF  ALVEOLAR 

ABSCESS. 

The  objective  as  well  as  the  subjective  symptoms  of  Alveolar 
Abscess  are  sufficiently  pronounced  to  prevent  any  mistake  in 
diagnosis.  That  which  is  under  special  consideration,  the  result 
of  the  infection  of  the  contents  of  a  pulp  chamber  or  canal,  begins 
with  a  pericementitis  that  gradually  increases  in  severity.  The 
soreness  is  extreme;  the  tooth  is  materially  lifted  in  its  socket  and 
becomes  loose,  with  that  peculiar  feeling  of  non-support  that 
indicates  fluid  at  the  extremity.  This  is  the  extravasated  lymph 
and  serum.  Within  a  few  hours  there  is  the  distinct  febrile  condi- 
tion, with  its  elevation  of  temperature,  quickened  pulse  and  suc- 
ceeding rigor — the  septic  fever  that  invariably  indicates  the  forma- 
tion of  pus  and  which  is  idiopathic.  The  red  line  or  red  blotches 
that  are  characteristic  of  pericemental  inflammation,  and  which 
are  peculiarly  observable  up  to  this  point,  now  begin  to  fade  away 


SYMPTOMATOLOGY    AND   TREATMENT    OF    ALVEOLAR    ABSCESS.       I29 

or  to  be  succeeded  by  a  deep  red  that  is  continuous  with  that  of  the 
neighboring  tissues,  and  there  is,  in  very  acute  cases,  a  tumor  or 
distention  of  the  alveolar  walls.  The  pain,  which  is  deep-seated, 
continuous,  and  of  a  boring  character,  is  now  intense,  but  there  is 
little  swelling  of  the  soft  tissues. 

The  pus  is  burrowing  its  way  toward  the  surface  of  the  bone, 
and  the  pressure  exerted  by  the  confined  matter  is  the  source  of  the 
suffering.  This  continues  until  the  alveolar  walls  have  been  pene- 
trated, and  the  pus  escapes  into  the  soft  tissues.  Great  swelling 
now  ensues,  with  subsidence  of  the  pain,  consequent  on  the  escape 
of  the  confined  fluid  into  the  tissues  that  can  yield  to  the  pressure. 
Sometimes  the  infiltration  of  the  tissues  and  diffused  cellulitis 
are  so  great  as  to  close  the  eye  and  greatly  distort  the  face.  But, 
although  the  appearance  at  this  stage  is  much  more  serious  and 
alarming  that  at  previous  ones,  the  pain  and  soreness  are  very 
much  less,  and  the  tension  is  relieved.  Finally,  there  is  "pointing," 
fluctuation  may  be  distinctly  detected  beneath  the  finger,  and  the 
abscess  is  ready  for  the  lancet. 

The  general  indications  of  a  septic  condition,  the  infection  by 
pyogenic  organisms,  and  the  formation  of  pus,  will  be  as  follows: 

1.  Anorexia,  or  loss  of  appetite  and  general  tone.  ' 

2.  Chills  or  rigors,  which  are  more  or  less  pronounced. 
5.  Headaches,  sharp,  persistent,  and  blinding. 

4.  Fever  of  a  distinct  type, — the  septic  fever. 

5.  Tongue  coated  and  covered  with  dark-colored  fur. 

6.  Constipation,  persistent,  hut  without  special  pain. 

7.  Urine  scanty,  of  high  color  and  speciHc  gravity. 

8.  Nervous  disturbance,  which  constantly  increases. 

The  latter  symptom  may  be  more  or  less  apparent,  depending- 
upon  the  gravity  and  severity  of  the  attack.  In  slight  cases,  like 
ordinary  alveolar  abscess,  it  may  amount  to  nothing  more  than 
uneasy  restlessness,  while  in  general  septic  conditions  there  may  be 
violent  delirium.  The  appearance  of  these  symptoms  marks  what 
is  called  "septic-"  or  "auto-intoxication,"  or  period  of  functional 
excitement  produced  by  the  absorption  of  septic  or  poisonous- 
matter. 

If  there  are  wounds  of  any  kind  through  which  infection  takes 
place  their  edges  will  become  red,  swollen,  tense,  and  angry  in 
appearance. 

10 


130  ORAL    PATHOLOGY   AND   PRACTICE. 

In  addition  to  these  general  indications  there  will  be  local 
manifestations,  which  may  assist  in  making  a  diagnosis. 

If  the  pus  pocket  is  superficial  there  will  be  "fluctuation,"  or 
that  feeling  beneath  the  finger  of  softening,  yielding,  and  undula- 
tion that  is  the  sure  sign  of  the  presence  of  a  fluid.  The  abscess  will 
begin  to  "point," — to  determine  toward  a  single  spot  and  to  show 
an  angry,  red,  or  softened  elevation  above  the  general  surface. 

If  the  pus  is  deep-seated  and  "pointing"  is  not  indicated,  or  is 
toward  some  cavity  within  the  body,  the  superincumbent  tissue 
will  appear  glistening,  and  will  lose  its  elasticity.  If  indented  with 
the  finger  it  will  blanch,  and  the  color  will  not  at  once  return  to  it 
upon  removal  of  the  pressure,  while  the  indented  pit  will  persist 
for  a  little  time  because  of  the  loss  of  resilience  or  springiness. 

■  Treatment. 

Abortive  measures  should  be  instituted  in  the  early  stages  of 
the  pericemental  iniiammation.  At  this  time  counter-irritants,  hot 
foot-baths,  with  laxatives  and  diaphoretic  remedies,  will  be  found 
useful.  If  a  dead  pulp  is  present,  the  pulp  chamber  should  be 
opened  under  the  strictest  antiseptic  precautions. 

The  rubber-dam  should  be  placed  upon  the  tooth,  to  segre- 
gate it  from  the  septic  fluids  of  the  mouth.  The  drill  should  be 
carefully  sterilized,  either  by  heat  or  by  being  allowed  to  remain  a 
little  time  in  some  germicidal  fluid.  Debris  should  be  removed 
from  the  cavity  of  decay,  if  such  cavity  exists,  and  it  should  be 
effectually  sterilized  with  a  bichloride  or  some  other  energetic 
solution.  As  soon  as  the  walls  of  the  pulp  chamber  are  punctured, 
the  drill  should  be  withdrawn  and  a  sterilizing  solution  injected  or 
carried  in  upon  a  pledget  of  cotton.  The  opening  may  now  be 
enlarged,  and  the  antiseptic  or  germicide  carried  to  every  possible 
point  of  the  pulp  cavity  and  canal.  With  a  sterilized  broach,  all 
debris  and  remains  of  the  decomposed  pulp  should  be  removed,  and 
the  canals  made  as  clear  of  obstruction  as  possible.  A  few  fibers 
of  cotton  dipped  in  some  antiseptic,  such  as  one  of  the  essential 
oils,  may  be  carried  as  near  the  apex  of  the  root  as  possible^  and 
sealed  up  in  the  cavity.  If  there  is  much  pain,  some  anodyne,  like 
tincture  of  opium,  may  be  introduced  into  the  canal  on  a  very  few 
fibers  of  cotton. 

This  treatment,  both  local  and  general,  should  be  continued 


SYMPTOMATOLOGY    AND   TREATMENT   OF   ALVEOLAR   ABSCESS.       I3I 

until  the  inflammation  with  its  soreness  and  pain  shall  have  passed 
away,  when  operative  measures  for  the  preservation  of  the  tooth 
and  its  protection  from  further  attacks  may  be  instituted. 

If  from  any  cause  the  treatment  shall  prove  ineffectual,  the 
inflammation  gradually  becoming  worse  until  the  symptoms  give 
Indication  that  resolution  cannot  be  expected,  that  degeneration 
has  already  commenced  and  septic  infection  has  taken  place,  the 
treatment  should  be  promptly  changed,  and  suppuration  encouraged. 
The  general  abortive  measures  must  be  abandoned,  and  the  pus 
directed  toward  the  surface.  Warm  fomentations  may  be  used,  a 
cloth  wrung  out  in  hot  water  being  applied  to  the  face  over  the 
seat  of  trouble,  and  carefully  covered,  while  the  patient  is  kept 
warm.  Indications  of  "pointing"  must  be  carefully  noted,  and 
any  tendency  toward  the  exterior  of  the  face  should  be  re- 
pressed by  painting  it  over  with  an  iodine  solution,  the  application 
of  cold,  and  other  like  measures.  A  poultice  consisting  of  the 
fresh  surface  of  a  split  fig,  or  raisin,  that  has  been  warmed  and 
softened  in  hot  water  and  sprinkled  with  capsicum  or  red  pepper, 
should  be  placed  over  the  alveolar  wall  opposite  the  root  of  the 
tooth,  or  within  the  oral  cavity  where  it  is  desired  that  the  abscess 
shall  point,  and  suppuration  invited  by  that  channel.  This  process 
should  be  hastened  by  every  available  means,  that  the  formation  of 
secondary  pockets,  with  osteitis,  or  inflammation  of  the  bone 
corpuscles,  may  be  avoided.  If  the  indications  are  that  the  pus  is 
burrowing  in  the  wrong  direction,  thus  threatening  a  prolongation 
of  the  condition,  with  the  probable  infiltration  of  the  bone  by 
septic  products,  the  practitioner  should  lose  no  time  in  reaching  the 
disturbed  place  with  an  instrument,  and  thus  establishing  a  sinus 
at  the  proper  point. 

The  pus  evacuated,  the  next  step  should  be  the  disinfection  of 
the  whole  territory.  The  pulp  chamber  should  be  opened  and 
cleaned  out,  and  the  principal  foraminal  opening  made  patulous. 
About  the  extremity  of  the  point  of  a  suitable  metal  syringe,  a  rope 
made  of  a  sufficient  quantity  of  cotton  fibers  dipped  in  a  chloro- 
percha  solution  may  be  wound,  the  point  introduced  into  the  cavity 
of  decay,  or  that  artificially  made  into  the  pulp  chamber,  and  the 
cotton  then  closely  packed  around  it.  The  barrel  of  the  syringe 
filled  with  tepid  water  may  now  be  attached  and  considerable  force 
used  until  the  stream  entering  at  the  pulp  chamber  emerges  at  the 


4 
132  ORAL    PATHOLOGY    AxVD    PRACTICE. 

fistulous  Opening.  The  barrel  of  the  syringe  is  now  removed  and 
filled  with  a  solution  of  three  per  cent,  pyrozone,  or  with  electro- 
zone,  and  this  is  injected  as  a  disinfectant.  This  is  succeeded  by 
a  solution  of  bichlorid  of  mercury  or  some  other  effective  germi- 
cide, and  the  cavity  may  be  sealed  up  for  a  day  or  two. 

It  may  be  advisable  to  wait  for  a  little  time  after  an  abscess 
shall  have  broken  or  been  opened  before  this  cleansing  and  steriliza- 
tion is  attempted,  that  the  pus  may  be  well  evacuated  and  the  acute 
symptoms  have  had  time  to  subside.  It  is  well  to  establish  the 
sinus  and  wash  out  the  tract  primarily,  because  if  a  coagulant  is 
employed  before  the  pus  is  removed  there  may  be  such  a  clot 
formed  as  will  effectually  stop  the  channel. 

If  at  the  end  of  sufficient  time  the  indications  warrant  the 
belief  that  sterilization  is  complete,  and  that  there  are  no  secondary 
pockets  of  infection,  the  root  may  be  permanently  filled.  If,  how- 
ever, the  septic  condition  continues  in  the  least  degree,  or  if  there 
are  signs  of  osteitis,  the  cavity  should  be  opened  and  the  sterilizing 
process  repeated,  or  an  antiseptic  anodyne  introduced  still  further 
to  test  the  case. 

If  the  fistula  is  an  old  one  and  the  abscess  not  of  recent  forma- 
tion, and  especially  if  there  are  no  acute  symptoms,  thus  indicating 
a  chronic  condition,  something  more  active  should  be  introduced 
as  an  antiseptic.  After  the  cleansing  out  of  the  pulp  chamber  and 
the  root  canal,  the  rubber-dam  should  be  applied  and  a  broach 
wound  with  cotton  fibers  dipped  in  a  saturated  solution  of  carbolic 
acid  introduced,  and  the  caustic  antiseptic  pumped  through  the 
tooth  and  along  the  sinus  until  it  appears  at  the  fistulous  opening, 
where  it  may  readily  be  detected  by  its  turning  the  tissues  white. 
This  cauterizes  the  whole  tract,  inducing  sloughing  to  a  limited 
extent,  and  brings  on  acute  symptoms,  with  eflfusion  of  plastic 
lymph,  which  in  the  thoroughly  sterilized  territory  may  be  built 
into  tissue  by  regular  progressive  metamorphosis. 

A  solution  of  chloride  of  zinc,  five  grains  to  the  ounce,  may  be 
forced  through  with  a  syringe  in  these  chronic  cases,  and  this  may 
bring  about  an  acute  condition  and  stimulate  the  indolent  functional 
activity.  Some  operators  proceed  at  once  to  fill  after  a  single  treat- 
ment such  as  has  been  indicated,  but  unless  there  are  special  rea- 
sons for  haste  it  is  better  and  safer  to  wait  until  it  has  been 
thoroughly  demonstrated  that  there  are  no  secondary  pockets  or 


SYMPTOMATOLOGY    AND    TREATMENT    OF    ALVEOLAR   ABSCESS.       1 33 

foci  of  infection,  and  until  the  reparative  process  and  the  up- 
building- of  the  waste  territory  has  fairly  commenced.  This  may 
usually  be  determined  by  the  dryness  of  the  root  canal.  To  test 
this  a  fine  broach  should  be  thrust  to  the  apex  of  the  root,  or  as 
far  as  possible,  quickly  withdrawn  and  wiped  upon  a  piece  of 
rubber-dam.  Any  moisture  will  show  at  once,  and  will  indicate 
that  there  is  still  a  septic  condition. 

There  are  instances  in  which  it  is  impossible  to  force  fluids 
through  the  foraminal  opening  or  openings.  This  will  more  fre- 
quently be  the  case  with  the  molar  teeth,  in  which  perhaps  the 
infected  point  will  be  at  the  opening  of  one  of  the  buccal  roots,  but 
it  may  occur  with  even  the  anterior  teeth.  Some  operators  insist 
that  they  are  able  to  open  the  apices  of  such  roots  with  a  drill,  but 
when  it  is  recollected  that  seldom  or  never  is  the  foraminal  opening 
in  a  direct  line  with  the  canal,  it  will  be  found  that  none  except 
men  of  the  most  phenomenal  skill  will  be  equal  to  this  task.  The 
average  operator  will  hesitate  before  proceeding  to  such  heroic 
measures. 

If  it  is  impossible  to  pass  a  flexible  broach  through  the 
foraminal  opening-,  or  to  establish  communication  between  the  out- 
side and  the  inside  of  the  apex  of  the  tooth,  after  the  cleansing  of 
the  canal  and  the  use  of  the  general  remedies  recommended,  the 
antiseptic  may  be  introduced  on  a  few  fibers  of  cotton  as  near  the 
apex  as  possible,  and  then  sealed  up  within  the  tooth.  The  agent 
used  should  be  one  that  is  of  as  penetrating  a  nature  as  possible, 
and  the  experiments  of  Miller  show  that  in  this  respect  none 
possess  any  special  advantage  over  pure  carbolic  acid.  The  pulp 
chamber  and  canal  should  be  completely  flooded  with  the  remedy, 
and  it  should  be  changed  as  often  as  necessary,  sometimes  every 
hour,  until  the  pulp  canal  is  thoroughly  and  completely  sterilized. 
Then  by  slow  infiltration  and  absorption  it  will  be  carried  beyond 
the  apex  of  the  tooth  and  sterilize  the  investing  tissues.  'It  may  be 
necessary  to  continue  such  treatment  for  some  time,  especially  when 
the  inflammation  is  of  an  indolent,  subacute  character.  But  when 
the  process  is  complete  the  sinus  that  may  have  existed  will  dis- 
appear, and  all  inflammatory  signs  will  depart. 

Treatment  from  the  outside  is  the  only  resource  in  those  in- 
stances in  which  none  of  the  usual  curative  measures  are  effectual. 
Sometimes  it  is  impossible  to  get  through  the  foraminal  opening. 


134  ORAL    PATHOLOGY    AND    PRACTICE. 

or  perhapi  the  dentist  has  been  too  precipitate  in  filling  the  root 
and  tooth  with  a  material  that  it  is  difficult  to  remove.  In  such 
a  case  the  seat  of  disturbance  must  be  reached  by  establishing 
a  sinus,  or  through  that  already  in  existence.  With  a  properly 
shaped  spring-tempered  probe  it  is  usually  possible  to  follow  the 
course  of  a  discharging  canal  to  the  apex  of  the  root.  A  few  fibers 
of  cotton  wet  with  a  solution  of  carbolic  acid  should  first  be  intro- 
duced as  an  obtundent  and  cauterant,  and  allowed  to  remain  for  a 
short  time.  The  probe  is  then  introduced  and  the  sinus  carefully 
explored  to  its  extremity.  It  will  usually  be  found  that  the  open- 
ing through  the  external  alveolar  wall  is  considerably  above  the 
fistulous  opening,  and  its  course  may  not  be  a  direct  one.  But  a 
little  patience,  with  the  knowledge  obtained  by  some  experience, 
will  enable  one  to  reach  the  apex  of  the  root  with  comparative 
readiness,  provided  the  lesion  is  not  upon  the  palatal  root  of  a 
superior  molar.  Having  clearly  outlined  it,  the  opening  may  now 
be  enlarged  with  a  trephine  or  drill,  if  it  is  necessary,  and  the 
proper  remedies  carried  to  the  diseased  point.  Deposits  may  be 
removed  from  the  root,  or  its  apical  point  amputated  if  necessary. 
All  debris  having  been  removed,  and  the  parts  carefully  sterilized, 
granulation  from  the  bottom  will  probably  close  up  the  opening. 
If  it  does  not,  the  operator  may  be  assured  that  there  is  dead  or 
foreign  matter  in  the  cavity,  or  that  it  has  not  been  effectually 
sterilized. 

In  filling  a  sterilized  devitalized  root,  it  is  not  at  all  essential 
that  the  filling  material  shall  be  pushed  farther  than  the  junction 
of  the  dentine  and  cementum,  at  the  point  where  the  division  of  the 
canal  into  the  foraminal  delta  begins.  The  broach  will  readily 
indicate  this  point,  because  it  is  sensitive  beneath  it.  It  is  only  the 
dentine  that  is  devitalized,  the  cementum  which  forms  the  real 
apex  of  the  root  retaining  its  vitality.  The  delta  or  divided  canal 
exists  within  the  living  cementum,  and  hence  does  not  need  to  be 
filled.  Dentists  sometimes  find  this  point  exceedingly  sensitive, 
and  imagine  that  the  pulp  is  not  yet  wholly  devitalized.  They  per- 
haps introduce  a  second  application  of  arsenical  paste,  and  so  do 
considerable  injury.  They  should  remember  that  the  cementum  at 
the  apex  is  probably  in  an  irritable  condition,  and  needs  an  anodyne 
rather  than  another  dose  of  a  corrosive  poison,  the  effect  of  which 
upon  the  already  inflamed  living  corpuscles  may  be  to  induce  death 
of  the  cemental  apex  and  necrosis  of  the  investing  tissues. 


DEPOSITS    UPON    THE   TEETH.  1 35 

There  are  instances  in  which  the  inflammation  stops  short  of 
the  formation  of  pus  and  results  in  an  indurated  mass,  sometimes 
of  considerable  size.  The  plastic  exudate  has  been  poured  out,  and 
has  infiltrated  the  tissues  and  caused  a  distinct  swelling.  But  the 
degenerative  process  has  not  begun,  either  because  there  is  no 
septic  infection  or  because  sterilization  has  destroyed  the  organism. 
The  inflammation  is  of  a  low,  subacute  character,  and  there  is  no 
pain  or  violence.  The  plastic  exudate  loses  its  usual  consistence, 
either  through  the  extraction  of  its  watery  part  or  because  of  some 
fibrous  organization  or  other  change,  and  becomes  indurated. 
The  swelling  is  perhaps  within  the  bone,  and  there  is  a  distinct 
protrusion  of  the  external  wall.  This  condition  may  remain  for 
an  indefinite  time,  and  it  sometimes  causes  considerable  deformity 
of  the  jaws. 

If  this  is  the  result  of  a  pericemental  inflammation  at  the  apex 
of  a  devitalized  tooth,  resolution  or  reabsorption  may  usually  be 
brought  about  by  the  injection  through  the  tooth  of  tincture  of 
iodine.  If  the  foraminal  apex  is  not  open,  cotton  saturated  with 
tincture  of  iodine  may  be  sealed  up  in  the  tooth  cavity,  and 
changed  as  necessity  requires,  until  the  process  is  completed.  If 
the  offending  tooth  is  extracted,  there  will  usually  be  immediate 
resolution,  but  this  is  not  always  advisable,  and  the  iodine  treat- 
ment may  be  resorted  to  for  the  slow  relief  of  the  indurated  con- 
dition. 


CHAPTER  XXIX. 

DEPOSITS  UPON  THE  TEETH. 

Under  this  head  will  be  considered  such  superficial  precipi- 
tates of  inorganic  matter  as  may  induce  possible  pathological 
changes.  They  must  be  derived  either  from  external  sources  or 
from  some  of  the  fluids  of  the  mouth  or  the  body.  There  are 
many  forms  of  oral  debris,  the  sediments  of  organic  matter, 
deposits  of  food,  etc.,  that  will  not  properly  come  within  this  cate- 
gory. The  "white  deposit,"  that  cheesy  depO'sition  that  is  so  often 
found  encircling  the  cervical  portion  of  the  tooth  and  forming  a 


136 


ORAL    PATHOLOGY    AND    PRACTICE. 


narrow  white  line  just  at  the  gum  margin,  belongs  to  the  latter  class. 
Jt  is  composed  of  the  debris  of  food  that  is  partially  fermented, 
micro-organisms,  etc.,  and  when  it  has  been  allowed  to  remain 
for  any  length  of  time  the  tissue  immediately  beneath  it  will  be 
found  partially  decalcified  and  softened.  But  the  deposit  it- 
self is  not  of  a  calcareous  nature,  and  is  easily  removed  by  the 
brush. 

The  so-called  "green  stain"  of  childhood  is  wholly  superficial 
and  has  no  special  patholog^ical  signification,  except  so  far  as  it  may 
be  a  symptom  of  some  unhealthy  condition  of  the  fluids  of  the  mouth. 
It  is  called  "green"  stain,  although  it  may  be  dark,  or  bronze,  or 
yellow  in  color.  It  has  by  some  been  considered  a  disease-pro- 
ducing kind  of  fungus,  which  penetrates  the  substance  of  the 
enamel,  disintegrating  it,  and  thus  injuring  the  tooth.     But  if  one 

Fig.  39. 


Green  Stain  on  the  Approximal  Surfaces  of  Incisors. 
(W.  D.  Miller.) 


will  immerse  a  tooth  discolored  by  it  in  a  ten  per  cent,  solution  of 
lactic  acid  he  will  in  a  few  moments  see  the  so-called  Nasmyth's 
membrane  separate  from  the  tissue,  and  it  will  carry  with  it  all  the 
deposit,  leaving  the  exterior  white  and  uneroded.  Sometimes  it  is 
found  upon  the  surface  of  eroded  or  even  decayed  enamel,  but  it 
can  be  removed  in  such  a  manner  as  clearly  to  indicate  that  it  was 
deposited  subsequent  to  the  erosion  or  caries.      (See  Fig.  39.) 

Salivary  calculus  is  a  deposit  from  the  saliva.  If  one  will 
through  a  tube  breathe  into  a  glass  of  lime-water,  he  will  soon 
observe  that  the  fluid  becomes  milky  in  appearance.  If  he  will 
continue  the  process  for  a  while,  and  then  set  the  glass  where  it 
will  be  entirely  undisturbed,  he  will  after  a  time  find  deposited 
upon  the  bottom  more  or  less  of  a  fine  amorphous  powder.     This 


DEPOSITS    UPON    THE   TEETH. 


137 


is  the  calcium  that  was  held  in  solution  in  the  water,  and  which 
was  thrown  down  as  carbonate  of  lime.  A  few  drops  of  hydro- 
chloric acid  will  clear  up  the  fluid  by  again  dissolving  the  pre- 
cipitate. 

It  is  not  asserted  that  this  is  the  method  in  which  salivary 
calculi  are  formed,  but  it  illustrates  the  precipitation  of  calcific 
matter.  The  calcium  salts  are  really  held  in  solution  in  the  saliva 
by  means  of  the  carbon  dioxide  which  it  contains.  When  the  fluid 
enters  the  oral  cavity  it  at  once  encounters  acids  which  may  be 
present,  and  is  subjected  to  fermentative  and  other  active  and 
chemical  influences,  which  result  in  the  precipitation  of  the  calcium 
salts,  and  these,  with  som.e  extraneous  matter,  form  the  calculi. 
Naturally,  this  deposition  will  be  greatest  near  the  mouths  of  the 
salivary  ducts,  and  so  the  principal  calculi  are  upon  the  inferior 

Fig.  40. 


A.  Salivary  Calculus  Causing  Rkckssion  of  Gum  and  Absorption  of  Alveolus. 

B.  Molar  with  Deposits  of  Sanguinary  Calculus  at  b.    At  a  Necrotic   Perice- 
mentum and  Broken  Down  E.xudate. 

incisors,  opposite  the  mouths  of  Wharton's  duct,  and  upon  the 
superior  molars  in  the  neighborhood  of  the  discharging  mouth  of 
the  duct  of  Steno.     (See  Fig.  40,  a.) 

Sometimes  this  material  is  precipitated  in  great  quantities, 
binding  several  teeth  together  in  one  mass.  In  some  instances  the 
utmost  care  of  the  patient  will  not  enable  him  to  keep  the  teeth 
entirely  free  from  it.  When  this  is  the  case  it  is  usually  soft,  of  a 
creamy  yellow  color,  and  is  easily  removed.  When  it  is  deposited 
more  slowly  it  has  time  for  consolidation  and  becomes  hard,  and  is 
usually  stained  a  dark  color  by  pigmentary  matter  from  the  oral 
cavity. 


138  ORAL    PATHOLOGY   AND   PRACTICE. 

It  has  no  special  pathological  signification  aside  from  the  fact 
that  it  is  a  mechanical  irritant,  and  keeps  the  teeth  and  mouth  in 
a  filthy  condition  by  constantly  acting  as  an  absorbent,  and  as  an 
obstruction  against  or  under  which  food  debris  lodges.  It  should 
be  carefully  removed  with  instruments,  the  teeth  polished,  and,  if 
necessary,  the  irritated  gums  touched  with  a  stimulating  astrin- 
gent. 

The  so-called  sanguinary  or  serumal  calculus  is  distinguished  by 
separate  characteristics,  and  is  due  to  other  or  modified  conditions. 
It  is  not  found  external  to  the  margins  of  the  gums,  nor  does  it 
always  appear  to  be  a  precipitate  from  the  oral  fluids, — for  no  refer- 
ence is  here  intended  to  the  hard,  black,  smooth,  supragingival,  slow 
deposit  which  is  but  a  modification  of  the  usual  form  of  calculus  and 
is  undoubtedly  of  salivary  origin.  The  so-called  serumal  deposits 
are  upon  the  periphery  of  a  root  that  is  not  denuded  when  they  are 
formed.  They  may  be  found  when  there  is  absolutely  no  break  at 
the  gingival  border,  and  when  consequently  their  precipitation  from 
the  oral  fluids  would  seem  to  be  an  utter  impossibility.  Instances 
of  this  are  cited  in  the  chapter  on  Pyorrhea.      (See  Fig.  40,  b.) 

It  is  not  deposited  in  a  smooth,  continuous,  amorphous  mass,  as 
in  the  case  of  salivary  calculus.  It  is  found  in  dense,  hard,  closely 
attached,  separate  nodules,  which  may  by  further  deposition  become 
confluent. 

It  cannot  be  scaled  off  cleanly  and  readily,  as  can  the  oral 
variety.  It  clings  so  closely  as  to  make  it  necessary  to  chisel  it 
away,  in  which  process,  unless  great  care  is  used,  a  scale  of  the 
tooth  may  be  taken  or  a  thin  layer  of  the  deposit  left.  It  has  not 
the  same  color  as  the  salivary  concretion,  the  latter,  except  when  it 
has  been  discolored  by  subsequent  pigmentary  deposits  or  infiltrates, 
being  of  a  dark  yellow  or  yellowish  white  color.  The  so-called 
serumal  or  sanguinary  deposit  is  of  an  olive-black  tint,  with  some- 
times an  olive-green  tinge.  It  is  not  identical,  either  in  color  or 
in  manner  of  deposition,  with  salivary  concretions. 

It  is  more  distinctly  irritating  to  the  tissue  than  is  the  salivary 
deposit.  Perhaps  the  location  of  it  within  the  tooth  socket  may 
serve  to  account  for  the  difference,  but  aside  from  that  there  appears 
tC'  be  a  rather  distinctive  irritation  in  its  presence,  not  known  in 
connection  with  the  salivary  deposit. 

Chemical  analysis  shows  that  there  is  a  synthetic  difiference 


DEPOSITS   UPON    THE   TEETH.  1 39 

between  the  two,  for,  while  calcium  forms  the  base  of  both,  the 
serumal  contains  certain  elements  not  found  in  the  other.  The 
analyses  of  it  have  not  been  sufficient  in  number  or  so  exhaustive 
in  character  as  to  reveal  all  that  may  probably  be  learned  from 
them. 

Perhaps  the  most  reasonable  and  consistent  theory  of  the 
formation  of  this  calculus  is  that  of  Professor  E.  C.  Kirk,  and  it 
may  be  thus  summarized :  The  capacity  of  the  blood  stream  for 
holding-  in  solution  the  waste  products  of  nitrogenous  metabolism, 
the  results  of  functional  activity  in  the  body,  is  determined  by  the 
alkalinity  of  the  blood  plasma.  Any  decrease  in  this  diminishes 
its  solvent  power  for  these,  and  causes  their  precipitation  in  the 
tissues  nourished  by  the  blood  stream.  This  lessened  alkalinity 
may  be  general,  affecting  the  whole  sanguinary  current,  or  it  may 
be  localized  in  certain  tissues;  in  the  latter  case  there  will  be  a 
localized  precipitation  of  the  products  of  which  uric  acid  is  a  type. 
Excessive  work  causes  an  increased  blood  supply  to  a  part,  and 
excessive  oxidation  and  tissue  waste,  which  in  turn  produce  les- 
sened alkalinity,  or  a  tendency  toward  acidity.  The  ligamentous 
tissues  are  especially  liable  to  conditions  of  this  nature,  and  the 
peridental  membrane,  belonging  to  this  category,  is  especially  sub- 
ject to  aifections  of  the  character  noted.  Excessive  work  being 
put  upon  the  investing  membrane  of  any  tooth,  through  mal- 
occlusion or  by  bad  habits  in  mastication,  by  injuries  from  wedging^ 
the  application  of  ligatures,  or  other  causes,  the  resulting  hyperemia 
brings  in  its  train  overnutrition,  localized  diminished  alkalinity ,^ 
with  the  consequent  deposition  of  urates. 

Professor  Kirk  believes  that  changes  identical  with  or 
analogous  to  those  cited  above  are  responsible  for  other  local  necro- 
biotic  degenerations.  They  may  be  the  exciting  cause  of  alveolar 
abscess,  through  a  diminishing  of  local  physiological  activity  and 
lessening  of  the  resistant  power  of  the  tissue,  which,  being  in- 
fected, leads  to  suppuration  of  the  pericementum,  that  has  been 
variously  denominated  pyorrhea  alveolaris,  phagedenic  perice- 
mentitis, or  suppurative  alveolitis.  Under  certain  other  definite 
conditions  the  pathological  changes  may  result  in  a  hyperplasia 
of  the  tissues,  and  hypercementosis  and  hypertrophies  of  the  peri- 
cemental membrane  may  be  the  result. 

It  is,  then,  accepted  that  this  calculus  is  and  must  be  derived 


140  ORAL    PATHOLOGY    AND    PRACTICE. 

from  the  blood,  through  the  pericementum.  Certain  it  would  seem 
to  be  that  the  trouble  is  not  in  the  tooth  itself,  for  the  cementum 
does  not  appear  to  be  affected  in  any  way,  further  than  secondarily 
through  the  mere  mechanical  separation  from  it  of  the  perice- 
mentum. One  reason  for  supposing  that  it  is  not  due  to  a  con- 
stitutional dyscrasia,  that  it  is  not  a  manifestation  of  a  general 
disorder,  but  rather  a  symptom  of  a  local  degeneration  or  disturb- 
ance, is  found  in  the  fact  that  it  is  usually  confined  to-  one  or  two 
teeth. 

The  early  presence  of  sanguinary  calculus  is  not  easily  deter- 
mined. Salivary  calculus  exhibits  itself  unmistakably  to  the  eye, 
and  so  there  can  be  no  error  in  its  diagnosis;  but  such  is  not  the 
case  with  the  sanguinary  concretion.  It  is  hidden  within  the  tooth 
socket  at  a  point  where  examination  is  impossible.  No  special 
prophylactic  measures  can  therefore  be  employed.  There  may  be  a 
localized  inflammation,  with  pustular  swelling,  but  this  comes  too 
late  for  preventive  measures.  When  a  pocket  reaching  down  to 
the  deposit  has  been  formed  from  the  gingival  margin,  there  is 
nothing  left  but  its  instrumental  removal. 

There  are  instances  in  which  pericemental  irritation  and  sore- 
ness may,  to  the  expert,  give  some  warning  of  nodular  formations. 
But  these  are  too  easily  confounded  with  those  which  may  be 
caused  by  hypercementosis,  or  by  the  presence  of  any  other 
foreign  substance,  to  afford  a  positive  pathognomonic  sign. 
When  we  comprehend  the  morbid  changes  of  the  disease  better 
perhaps  we  will  recognize  premonitory  indications,  but,  as  it  is,  we 
must  wait  for  its  development.  The  usual  revelation  will  come 
through  the  formation  of  the  characteristic  pockets  beside  the 
affected  tooth,  and  the  point  of  irritation,  when  near  the  apex  of 
the  root,  may  in  some  instances  be  detected  by  the  localized 
inflammation  and  swelling.  The  local  treatment  for  the  condition 
is  laid  down  in  the  chapter  on  Pyorrhea  Alveolaris. 


PYORRHEA    ALVEOLARIS.  I4B 

CHAPTER  XXX. 
PYORRHEA  ALVEOLARIS. 

Pyorrhea  Alveolaris  has  been  defined  by  Kirk  as  a  necrotic^ 
suppurative,  inflammatory  process  which  destroys  the  pericemen- 
tum, and  by  setting  up  an  osteomyelitis  in  the  alveolar  margins  sub- 
sequently destroys  them  also.  He  believes  it  to  be  caused  by  the 
invasion  of  certain  pathogenic  organisms  which  are  the  exciters 
of  the  inflammatory  process.  The  depth  of  the  bacterial  invasion 
determines  the  seat  or  location  of  the  inflammation,  and  is  condi- 
tioned upon  the  degree  of  vital  resistance  of  the  tissues  invaded. 
Given  low  vitality  in  the  pericemental  membrane,  the  invasion  is- 
deeper,  and  the  pyorrhea  is  established  by  the  breaking  down  of 
tissue  and  the  establishment  of  a  pocket  through  the  working  out 
of  the  products  of  the  inflammatory  action  at  the  gum  margin. 
Given  high  vital  resistance  in  the  pericemental  membrane,  the  dis- 
order produced  by  these  inciters  of  inflammation  becomes  superfi- 
cial ;  that  is,  ulcerative  in  type. 

The  depression  of  vital  resistance  may  be  either  constitutional 
or  local.  If  the  former,  it  is  brought  about  by  a  chronic  toxemia, 
the  result  of  auto-intoxication  caused  by  malnutrition  and  the  im- 
perfect elimination  of  the  waste  products  of  tissue  consumption  and 
repair.  These  toxic  substances  in  the  blood  stream  are  irritant  in 
character,  and  manifest  their  action  in  the  pericemental  membrane 
by  the  production  of  hypercementosis  and  by  other  changes.  When 
the  predisposing  factor  is  purely  local,  as  in  the  case  of  salivary 
calculus  impinging  on  the  gingival  margin,  the  depression  of 
vitality  is  entirely  superficial,  affecting  only  the  layer  of  cells  in 
contact  with  the  calculary  deposit.  The  invasion  of  pathogenic- 
germs  is  also  superficial,  the  high  vitality  of  the  healthy  tissue 
beneath  preventing  deep  invasion,  and  the  type  of  the  necrotic  and' 
inflammatory  process  is  ulcerative. 

It  is  not  a  matter  for  boastfulness  that  for  so  long  a  time  so- 
little  should  have  been  positively  known  concerning  a  disease  that,.. 
after  caries,  is  responsible  for  the  loss  of  more  teeth  than  any  other. 
It  is  but  recently  that  any  attention  whatever  has  been  paid  to  it. 
For  many  centuries  it  has  been  doing  its  destructive  work  withoiit: 


142  ORAL   PATHOLOGY   AND   PRACTICE. 

remark  and  without  any  attempt  to  determine  its  pathology.  Not 
alone  in  man  is  it  prevalent,  but  many  animals  suffer  from  fts 
ravages.  Domestic  cats  are  especially  liable  to  its  attacks,  while 
dogs  are  far  from  exempt.  Horses  sometimes  suffer  extremely 
from  pyorrheal  affections,  but  their  teeth  are  not  as  often  extruded 
and  lost,  because  of  the  length  and  shape  of  the  roots,  which  do 
not  end  in  a  closed  foraminal  opening.  None  of  the  teeth  of  per- 
sistent growth  in  the  various  orders  of  animals  are  materially 
affected  by  these  disorders,  so  far  as  the  author  is  aware.  But  he 
has  in  his  possession  the  skull  of  an  African  gorilla,  an  animal  that 
it  has  been  found  almost  impossible  to  keep  in  captivity,  in  which 
the  characteristic  appearance  of  this  disease  exists  unmistakably. 

The  condition  has  been  known  by  various  names.  The  late 
Dr.  J.  M.  Riggs,  of  Hartford,  Conn,,  was  probably  the  first  to  call 
public  attention  to  it,  about  the  year  1850.  For  some  time  it  was 
called  from  him  "Riggs's  Disease,"  but  the  impropriety  of  this 
beiiig  manifest,  the  term  Pyorrhea  Alveolaris  was  proposed,  and 
has  been  generally  accepted.  Prof.  G.  V.  Black  has  denominated 
it  "Phagedenic  Pericementitis."  Dr.  J.  N.  Farrar  has  proposed  the 
name  "Loculosis  Alveolaris,"  from  the  fact  that,  very  often  at 
least,  it  has  its  origin  in  a  kind  of  pocket  beside  the  alveolus. 
Others,  recognizing  a  communicable  nature,  have  denominated  it 
"Infectious  Alveolitis."  When  its  true  nature  and  exact  pathology 
are  more  fully  ascertained,  a  term  that  is  descriptive  of  it  will  un- 
doubtedly be  universally  accepted.  In  the  meantime  Pyorrhea 
Alveolaris,  which  signifies  a  discharge  of  pus  from  the  alveoli, 
although  somewhat  indefinite,  is  as  applicable  as  any. 

It  has  been  intimated  that  the  exact  nature  of  the  disorder 
has  not  yet  been  decisively  determined.  At  least  no  exposition  of 
it  has  been  commonly  accepted.  Many  theories  have  been  offered, 
and  some  of  exceeding  plausibility  are  now  before  the  dental  pro- 
fession ;  but,  so  far,  none  has  received  that  general  acceptance  which 
excludes  all  other  hypotheses.  That  its  seat  is  within  the  alveolar 
socket  is  easily  demonstrated,  and  that  either  the  tooth  root  or  its 
investing  membrane  is  an  essential  factor  in  its  existence  is  quite 
plain,  for  extraction  always  affords  a  radical  cure.  Beyond  this 
there  is  no  admitted  certainty  concerning  its  etiology.  Professor 
Black  believes  the  initial  point  to  be  in  the  pericementum.  Others 
have  held  that  it  commences  with  a  degenerative  condition  of  the 


PYORRHEA    ALVEOLARIS.  1 43 

investing  margin  of  the  alveolar  process.  Prof.  W.  D.  Miller  says 
that  there  are  three  active  factors  in  its  production:  constitu- 
tional diathesis,  local  causes,  and  micro-organisms. 

Perhaps  the  hypothesis  that  has  attracted  the  most  attention 
up  to  this  point  is  that  which  has  been  so  strenuously  urged  by 
Prof.  C.  N.  Peirce  and  others,  that  it  is  but  an  expression  of  the 
uric  acid  diathesis,  and  is  closely  allied  to  gout,  rheumatism,  and 
allied  disorders.  It  has  been  asserted,  indeed,  that  it  is  always  con- 
nected with  them,  either  as  a  forerunner,  a  successor,  or  a  substi- 
tute. It  has  been  argued  that  as  urea  is  the  effete  product  of  the 
using  up  of  tissue  in  functional  activity,  which  the  excretory  organs 
should  eliminate,  its  presence  in  the  body  is  an  indication  of 
inactivity  on  their  part.  It  is  undoubtedly  true  that  such  effete 
matter  must,  from  its  very  nature,  by  its  continued  presence  excite 
a  more  profound  influence  than  would  any  innoxious  foreign  sub- 
stance. We  all  know  the  extreme  violence  and  general  character 
of  the  protests  of  all  the  tissues  of  the  body  against  its  presence 
when  manifested  in  uremic  poisoning. 

The  dense,  hard,  dark-colored  nodules  sometimes  found  upon 
the  roots  of  teeth,  and  which  are  considered  in  Chapter  XXIX., 
dealing  with  salivary  and  sanguinary  calculi,  it  has  been  claimed 
are  induced  by  and  contain  the  urates  of  the  blood,  and  are  prime 
factors  in  inducing  the  pyorrheal  condition.  Could  these  asser- 
tions be  substantiated  as  indisputable  facts  in  all  cases,  they  would 
be  conclusive.  But  it  is  urged  in  answer  that  it  is  not  positively 
demonstrated  that  the  concretions  referred  to  have  their  origin  in 
the  blood,  that  they  are  necessarily  an  expression  of  the  uric  acid 
diathesis,  that  they  invariably  contain  any  uremic  salts,  are  at  all 
essential  to  the  pyorrheal  condition,  or  are  in  any  considerable 
proportion  of  instances  the  cause  of  it.  They  point  to  the  fact  that 
while  they  may  be  frequent  or  even  usual  concomitants,  pyorrhea 
exists  in  its  worst  form  without  the  presence  of  any  such  deposits, 
and  quite  unconnected  with  either  gout  or  rheumatism.  In  the 
midst  of  this  conflicting  mass  of  evidence  the  only  sure  conclusion 
at  which  it  is  possible  to  arrive  is  that  the  subject  has  not  yet  been 
sufficiently  considered,  and  that  we  have  not  verified  ultimate 
facts.  There  is  abundant  cause  for  investigation  and  observation, 
and  every  real  student  should  strive  to  add  something  to  the  knowl- 
edge of  the  subject,  until  enough  has  been  learned  to  form  a  basis 


144  ORAL   PATHOLOGY   AND    PRACTICE. 

on  which  to  build  an  hypothesis  that  shall  be  unassailable.  Some 
patient  investigator  will  yet  solve  the  problem,  as  Miller  gave  us 
the  solution  of  that  of  dental  caries,  which  was  for  so  long  a  time  in 
the  same  unsatisfactory,  unsettled,  disputed  condition.  In  the 
meantime  it  only  remains  practicable  to  present  as  clear  an  expo- 
sition as  the  present  state  of  knowledge  will  permit. 


CHAPTER  XXXI. 
PYORRHEA  ALVEOLARIS  (Continued). 

True  Pyorrhea  Alveolaris  should  he  a  manifestation  of  some 
distinct,  perhaps  specific,  pathological  condition.  The  term  itself, 
while  expressive  of  our  present  knowledge,  is  too  broad,  covering 
altogether  too  much,  for  there  are  many  exudations  of  pus  from 
the  alveolar  walls  that  are  easily  explainable,  and  of  very  simple 
origin.  But  until  its  exact  nature  is  distinctly  marked  out,  and  all 
its  phenomena  comprehended,  we  must  recognize  at  least  three 
separate  pathological  degenerations  that  are  covered  by  the  term,, 
and  which  without  doubt  are  often  confounded  with  each  other. 

The  first  of  these  will  be  entirely  local  in  its  character.  It 
will  have  its  origin  in  an  easily  comprehensible  cause — local  irrita- 
tion. 

The  second  will  have  its  etiology  in  deposits  of  a  hard,  nodular 
character  upon  the  roots  of  the  teeth.  It  will  be  distinguished  by 
the  formation  of  distinct  pockets  within  the  alveolus. 

The  third  will  give  evidence  of  some  distinct  cachectic  condi- 
tion or  dyscrasia.  It  will  present  phenomena  that  are  peculiar 
to  itself,  and  will  be  without  either  of  the  two  previously  named 
factors. 

The  first  condition  is  a  localized  gingivitis,  with  possible  alveo- 
lar caries,  or  a  slow  solution  of  the  alveolar  edges.  It  is  charac- 
terized by  inflamed,  turgid  gums,  which  are  everted  at  the  cervix.. 
There  will  probably  be  a  degenerate  mucous  secretion  of  a  viscid 
character  and  acid  in  reaction.  The  gum  is  not  adherent  to  the 
teeth,  and  the  point  of  an  instrument  can  be  passed  between  them. 
Instead  of  the  hard,  dense  appearance  that  the  gingivae  usually  pre- 
sent, they  bleed  at  the  slightest  touch.    A  little  pus  can  be  forced  out 


PYORRHEA    ALNEOLARIS.  145 

from  between  the  gum  and  tooth,  but  it  is  small  in  quantity  and 
thick  in  consistence.  The  jDatient  gives  the  teeth  but  little  care, 
and  they  usually  present  anything  but  a  healthy  appearance.  The 
redness  is  principally  confined  to  the  gum  margin,  and  there  are 
few  or  none  of  the  peculiar  red  blotches  higher  up  that  are  indica- 
tive of  pericemental  inflammation.  An  explorer  cannot  be  passed 
up  far  beneath  the  gum,  and,  with  the  exception  of  roughened 
edges,  the  alveolar  process  is  perfect. 

The  prognosis  of  this  condition  is  always  good.  The  first  care 
should  be  thoroughly  to  clean  the  teeth,  and  to  remove  from  about 
their  necks,  especially  from  beneath  the  gums,  any  foreign  sub- 
stances  that   may   have   accumulated.     Not    infrequently    delicate 

Fig.  41. 


Gingival  Destruction  of  the  Pericementum  with  Resorption  of  the  Alveolar 
Borders,  due  to  Pyorrhea  of  the  Third  Variety. 
There  are  no  deposits  and  little  if  any  suppuration.     The  destructive  process  has  entirely 
denuded  one  root,  and  the  alveolar  walls  inclosing  the  others  are  very  thin.     (Burchard.) 

rings  of  salivary  calculus  will  encircle  them  close  up  to  the  alveolar 
border.  All  traces  of  this  must  be  removed,  and  the  necks  of  the 
teeth  be  carefully  polished.  Sometimes  foreign  substances,  like 
slivers  from  wooden  toothpicks,  or  spiculse  of  bone  from  the  food, 
will  be  found  driven  beneath  the  gums,  and  these  will  be  the 
source  of  irritation.  After  careful  cleaning  the  gums  should  be 
well  rubbed,  and  a  soft  tooth-brush,  with  some  antiseptic  wash, 
should  be  prescribed.  Listerine  is  good  for  this  purpose,  or  any  of 
the  pleasant  essential  oils,  largely  diluted.  Care  and  cleanliness, 
with  the  removal  of  every  foreign  substance,  will  be  sufihcient  to 
produce  a  cure,  for  the  condition  was  only  the  result  of  a  lack  of 
attention,  and  the  irritating  presence  of  foreign  substances. 

The  second  condition  is  one  of  greater  moment.     It  is  charac- 


14,6  ORAL    PATHOLOGY    AND    PRACTICE. 

terized  by  the  presence  of  deep  pockets  in  the  alveolus,  at  one  side 
of  the  anterior  teeth,  or  perhaps  between  the  roots  of  the  premolars 
or  molars.  There  may  be.  little  of  the  turgidity  or  tumefaction 
described  in  the  previous  paragraph,  but  an  exploration  with  an 
instrument  will  detect  a  resorption  of  the  alveolar  walls  of  the  tooth 
socket,  and  pus  may  be  forced  out.  Often  the  tooth,  especially  if 
it  is  one  of  the  six  anterior  ones,  will  commence  an  inclination 
away  from  its  neighbor.  It  loses  its  upright  position,  perhaps  falls 
out  of  the  line  of  the  arch,  and  the  previous  regularity  of  a  well- 
ordered  dentition  becomes  sadly  broken.  The  affected  tooth  is 
always  deflected  from  the  side  on  which  is  the  pocket,  and  not 
toward  it.  A  more  careful  exploration  of  this  pocket  will  usually 
detect,  well  up  toward  the  apex,  or  along  the  body  of  the  root, 
dense,  hard,  gritty  nodules,  that  are  closely  attached  to  the  side  of 
the  root,  enveloping  more  or  less  of  the  surface  that  has  been 
denuded  of  its  pericemental  membrane,  but  which  is  yet  covered  by 
the  gum.  These  are  the  sanguinary  deposits  described  in  a  previ- 
ous chapter. 

Whether  these  are  the  cause  or  the  result  of  the  diseased  con- 
dition has  formed  a  fruitful  subject  of  discussion  among  etiologists. 
Those  who  believe  them  to  be  deposits  from  the  fluids  of  the  mouth 
insist  that  there  must  be  some  connecting  opening  between  them 
and  the  oral  cavity,  along  the  side  of  the  tooth.  But  competent 
observers  have  described  instances  in  which  there  absolutely  was 
none.  One  such  case  fell  within  the  observation  of  the  author. 
His  associate  in  practice  found  opposite  the  lower  third  of  the  root 
of  a  lower  central  incisor,  in  the  mouth  of  a  woman  who  took  excel- 
lent care  of  her  teeth,  a  peculiar  swelling  that  had  somewhat  the 
appearance  of  incipient  alveolar  abscess,  but  which  had  none  of  the 
other  symptoms  that  attend  that  disorder.  The  author  counseled 
pursuance  of  the  expectant  plan,  and  waiting  for  developments. 
In  a  very  few  days  pus  gathered  in  a  comparatively  small  amount, 
and  was  discharged.  The  opening  was  enlarged,  and  opposite  it 
were  the  characteristic  nodules  of  the  so-called  sanguinary  or 
serumal  calculus.  Yet  the  gingivae  were  absolutely  unbroken, 
and  there  was  not  the  slightest  indication  of  irritation  about  the 
neck  of  the  tooth.  The  nodules  were  carefully  removed,  the  open- 
ing antiseptically  dressed,  when  it  healed,  leaving  no  sign  whatever 
of  the  lesion,  nor  has  any  since  appeared.     If  the  hypothesis  pre- 


PYORRHEA   ALVEOLARIS.  I47 

sented  on  a  previous  page  is  accepted,  the  presence  of  these  nodules 
is  accounted  for.  But  there  were  in  this  patient  no  indications  of 
either  local  or  general  anemia  or  lack  of  tone,  while  the  tooth  was 
one  of  a  nearly  perfect  set,  a  lower  incisor,  not  subjected  to  unusual 
strain  or  labor.  Upon  removal  of  the  calculus  it  returned  to  a 
normal  condition,  and  has  so  remained  for  some  years. 

It  must  be  accepted  that,  in  some  instances  at  least,  the  semmal 
nodules  are  the  first  indications  of  the  disturbance.  Whether 
these  are  the  result  of  any  special  diathesis  we  need  not  now  further 
inquire.  We  know  that  they  are  specially  irritative  in  their  nature. 
If  they  form  the  initial  point  of  the  disorder,  the  subsequent  patho- 
logical changes  may  be  easily  comprehended.  They  lift  the  peri- 
cementum from  the  tooth,  and  by  their  presence  originate  the 
breaking  down  of  tissue.  Infection  follows,  and  the  pus  forces  its 
way  to  the  gingival  margin,  thus  making  an  opening  into  the 
pocket  already  formed.  Or  perhaps  the  pocket  is  completed  by  the 
continuation  of  the  deposits  to  the  gum  margin,  the  infection  being 
subsequent  to  this.  Perhaps,  in  a  proportion  of  the  cases,  the 
deposition  of  the  calculus  commences  at  the  neck  of  the  tooth  and 
proceeds  toward  the  apex,  forming  the  pocket  from  the  margin 
instead  of  from  the  interior  of  the  alveolar  socket.  In  any  case, 
there  must  be  organic  or  functional  degeneration  of  the  perice- 
mental membrane  as  the  immediate  or  proximate  cause  of  the  dis- 
turbance, and  the  attention  of  the  practitioner  should  be  directed 
toward  such  local  or  constitutional  remedies  as  will  prove  effectual. 

The  prognosis  of  this  condition  depends  upon  the  ability  com- 
pletely to  remove  the  deposits,  and  upon  the  general  tone  of  the 
system,  or  its  ability  to  bring  about  a  restoration  of  the  lost  tissue, 
and  a  healthy  tone  in  that  which  remains.  The  first  remedial  meas- 
ure is  thoroughly  to  cleanse  the  teeth  and  pockets.  This  must  be 
the  work  of  time  and  patience.  If  the  disease  has  extended  so  far 
as  to  induce  much  soreness  and  looseness  of  the  tooth,  it  cannot  be 
accomplished  without  considerable  pain.  So  dense  and  closely 
attached  is  the  deposit  in  many  cases  that  a  sharp,  stiff  chisel,  with 
considerable  force,  is  demanded.  The  drawing  motion  of  a  scraper 
is  insufficient.  Only  the  thin  edge  of  a  chisel  will  reach  the  last 
particle,  which  may  lie  just  at  the  point  of  separation  of  the  perice- 
mentum from  the  tooth. 

There  is  no  chemical  agent  that  can  be  depended  upon  to  dis- 


148  ORAL   PATHOLOGY    AND    PRACTICE. 

solve  the  deposits  away  without  injury  to  the  surrounding  bone  and 
tooth.  The  usual  mineral  acids  attack  the  latter  quite  as  readily  as 
the  concretion.  Trichloracetic  acid  has  been  found  of  benefit  in 
softening  it,  so  that  it  may  more  readily  be  rem.oved  with  instru-  * 
ments.  This  may  be  used  in  from  twenty  to  fifty  per  cent,  aqueous 
solution,  the  exact  strength  to  be  determined  by  trial.  It  should 
be  carried  to  the  extremities  of  the  pocket  on  a  narrow,  wedge- 
shaped  piece  of  orange  wood  that  has  been  dipped  in  the  solution, 
and  by  a  pumping  motion  continued  for  a  sufficient  length  of  time 
every  nodule  may  be  saturated  with  it.  Or  it  may  be  carried  upon 
a  rope  consisting  of  a  few  fibers  of  cotton  wet  with  the  acid.  Dr. 
W.  J.  Younger,  who  has  made  a  specialty  of  the  treatment  of 
pyorrhea,  uses  and  recommends  lactic  acid  for  the  same  purpose^ 
and  claims  that  it  has  special  therapeutic  value  in  this  disease. 

It  may  be  necessary  to  repeat  the  operation  more  than  once, 
carefully  chiseling  or  scraping  off  all  that  is  practicable  each 
time,  until  the  root  is  clean  and  polished.  The  pockets  should  be 
washed  out  and  treated  antiseptically.  Finally,  when  all  the  deposits 
are  removed,  a  weak  solution  of  chloride  of  zinc  may  be  injected  as 
a  stimulating  astringent.  It  may  be  necessary  to  freshen  the 
alveolar  edges  with  a  hoe  excavator,  or  a  safe  bur,  to  induce  new 
granulations.  When  there  has  been  an  effusion  of  coagulable 
lymph  it  should  be  protected,  and  not  carelessly  wiped  or  washed 
away.  To  this  end  it  is  necessary  to  know  when  to  stop  active 
surgical  or  operative  measures,  and  to  leave  the  rest  to  the  vis 
medicatrix  natures.  Pursuing  this  course,  the  author  has  had  the 
great  satisfaction  of  seeing  pockets  that  reached  almost  or  quite 
to  the  apex  of  the  root,  and  into  which  a  considerable  quantity  of 
cotton  could  be  packed,  completely  healed  and  filled  with  a  new 
growth  of  bone  through  the  action  of  a  newly-formed  perice- 
mentum. 

The  prognosis  of  the  third  condition  is  almost  invariably  bad. 
It  seems  to  be  connected  with  some  vicious  constitutional  condi- 
tion that  prevents  eradication  of  the  disease.  There  is  frequently  T 
very  little  if  any  gingival  inflammation.  There  is  no  thickening 
or  tumefaction,  and  but  little  redness  of  the  gums.  Perhaps  they 
may  even  be  abnormally  pale  and  bloodless.  There  are  none  of 
the  pockets  of  the  preceding  conditions,  but  there  is  a  steady 
wasting  of  the  alveolus,  a  continual  recession  of  the  gums,  with 


PYORRHEA    ALVEOLARIS.  1 49 

a  constant  and  sometimes  profuse  discharge  of  pus  from  the 
sockets  of  the  teeth.  In  the  pocket  form  a  single  tooth  may  be 
affected,  but  in  this  state  it  usually  spreads  from  tooth  to  tooth, 
until  all  or  nearly  all  of  either  or  both  jaws  become  affected.  There 
is  no  special  pain,  or  any  great  degree  of  soreness  until  the  later 
stages  are  reached,  when  the  loss  of  the  teeth  seems  imminent,  and 
when  the  destruction  of  tissue  goes  on  with  such  rapidity  that  it 
almost  assumes  the  acuteness  of  alveolar  abscess. 

There  may  be  no  deposits  of  any  kind.  The  condition  may 
occur  in  the  mouths  of  those  who  are  fastidious  in  the  care  of  their 
teeth,  and  who  regard  its  insidious  but  sure  advances  with  horror. 
They  fight  it  with  every  weapon  at  command.  They  may  retard  it 
for  years,  but  it  is  seldom  that  it  is  entirely  eradicated.  The  author 
has  under  his  care  cases  in  which  it  manifested  itself  twenty- 
five  years  ago,  and  though  it  has  been  kept  in  check,  sometimes 
by  the  most  radical  measures,  it  still  crops  out  occasionally,  and 
he  and  his  patient  have  never  been  long  entirely  separated. 

When  a  radical  cure  of  this  form  of  the  disease  has  been 
effected,  it  has  usually  been  because  of  some  constitutional  change 
in  the  general  tone  of  the  sufferer.  It  has  ever  been  prone  to  attack 
anemic  and  atonic  persons,  though  it  is  not  confined  to  them,  and 
when  it  has  been  eradicated  it  has  been  accompanied  by  a  com- 
plete change  in  the  bodily  health  of  the  patient,  and  a  return  to  a 
tonic  state. 

The  treatment  of  this  special  condition  must,  to  a  considerable 
degree,  be  general  in  its  nature.  If  it  is  due  to  a  want  of  eliminative 
power  in  the  body,  it  may  be  that  a  prolonged  course  of  alterative 
End  tonic  treatment  will  be  necessary  to  enable  the  system  to  recover 
and  maintain  its  normal  tone.  If  there  is  any  distinct  diathesis 
with  which  it  may  be  connected,  that  should  be  attended  to. 
Antiseptics  must  be  constantly  used,  and  the  mouth  kept  as  free 
from  putrefaction  as  possible.  Stimulating,  astringent  mouth- 
washes should  be  frequently  employed,  and  every  hygienic  pre- 
caution exhausted.  The  space  between  the  gum  and  the  tooth 
should  be  kept  clean,  and  whenever  necessary  it  should  be  wiped 
out  with  some  mild  cauterant,  like  lactic  or  trichloracetic  acid. 
Massage  should  frequently  be  employed  by  rubbing  the  gum  with 
the  ball  of  the  finger,  using  considerable  force.  The  tooth-brush 
should  not  be  too  hai-sh,  and  washes  rather  than  powders  should  be 
employed  with  it. 


150  ORAL    PATHOLOGY   AND    PRACTICE. 

In  some  instances  the  author  has  seen  what  he  thought  to  be 
good  results  following  the  use  of  anti-gout  and  rheumatic  remedies. 
The  employment  of  lithia  in  some  form,  or  of  salicylic  acid,  has 
been  especially  recommended.  Dr.  E.  C.  Kirk  has  reported  excel- 
lent results  from  a  persistent  use  of  lithium  bitartrate,  in  the  form 
of  tablets. 

If  a  tooth  becomes  very  loose  through  destruction  of  the 
alveolar  socket  it  is  usually  best  to  remove  it,  but  when  it  is  the 
result  of  an  acute  inflammatory  stage,  it  may  be  held  firmly  for  a 
time  by  weaving  a  ligature  about  it  and  the  adjoining  teeth. 
Sometimes  there  may  be  a  decided  amelioration  following  the 
burring  away  of  the  diseased  edges  of  the  alveolar  process,  with  the 
use  of  antiseptics  and  stimulating  astringents,  but  too  often  this  is 
not  permanent.  Very  little  dependence  can  be  placed  upon  the 
many  specific  methods  and  remedies  offered  by  those  who  claim  to 
cure  the  incurable.  The  best  results  will  be  attained  by  the  practi- 
tioner who,  to  general  medical  intelligence,  adds  the  most  faithful, 
diligent,  painstaking  care  in  the  line  of  treatment  adopted.  Of 
course,  when  the  whole  or  nearly  the  whole  alveolar  socket  of  a 
tooth  has  been  lost,  further  temporizing  methods  are  useless. 


CHAPTER  XXXII. 
FACIAL  NEURALGIAS. 


Neuralgias  are  affections  of  a  nerve  trunk  or  filament,  and  may 
be  either  organic,  constitutional,  functional  or  local  in  their  origin. 
The  first  of  these  occur  through  some  organic  change  in  the  tissues 
which  renders  them  incapable  of  healthy  action.  The  second  arise 
from  and  are  associated  with  a  constitutional  diathesis.  The  third 
are  due  to  disturbed  nutrition  and  the  consequent  lack  of  tone, 
while  the  fourth  originate  in  a  direct  lesion,  or  in  some  local  irrita- 
tion. An  instance  of  the  first  is  the  pain  due  to  cicatrization  of  a 
wound ;  of  the  second  the  general  neuralgia  of  gout  or  syphilis ;  of 
the  third  that  of  miasmatic  affections,  while  the  fourth  may  be 
found  in  prolonged  dental  disturbances.  Strictly  speaking,  any 
pain  is  a  neuralgia,  but  the  usual  signification  is  confined  to  an 
affection  in  a  nerve  trunk  as  distinguished  from  that  caused  by 
irritation  of  a  terminal  filament.     The  continued  pain  arising  from 


FACIAL    NEURALGIAS.  I5I 

a  neuromatous  tumor  is  an  instance  of  neuralgia  from  a  true  lesion 
of  a  nerve  trunk. 

True  neuralgias  are  principally  confined  to  the  afferent  nerves, 
but  they  may  be  reflex  and  hence  have  their  origin  in  the  efferent 
or  motor  nerves.  The  facial  neuralgias  that  form  the  majority  of 
the  affections  presented  to  the  notice  of  the  dentist  are  manifested 
in  the  trigeminus,  and  their  most  frequent  cause  is  diseased  teeth. 
The  irritation  from  caries  may  be  so  severe,  or  so  long  continued, 
that  the  trunk  of  the  nerve  is  affected  and  its  function  so  modified 
that  it  remains  in  a  permanently  irritable  condition. 

The  diagnosis  of  this  disorder  is  not  always  easy.  That  is,  it  is 
sometimes  difficult  to  determine  whether  the  pain  arises  from  a 
mere  local  irritant,  like  the  inflamed  pulp  of  a  tooth,  or  if  it  is  a  true 
degeneration  or  functional  disturbance  of  the  nerve  tissue.  In 
facial  neuralgia  the  first  thing  to  do  is  to  look  for  the  cause,  and  to 
determine  whether  it  may  not  be  mere  odontalgia,  or  toothache. 
To  this  end  the  most  minute  examination  of  the  teeth  upon  the 
affected  side  should  be  made.  Cavities  may  exist  beneath  the  gums 
which  only  the  most  careful  search  will  reveal.  Every  test  for  in- 
flamed and  irritated  pulps  should  be  tried,  and  in  the  great  majority 
of  instances  the  suspected  neuralgia  will  be  found  to  be  mere  tooth- 
ache. 

Every  local  cause  having  been  excluded,  the  general  bodily 
condition  should  be  noted.  If  any  distinct  diathesis  exists,  like 
that  of  gout,  rheumatism,  syphilis,  malaria,  or  catarrh,  its  possible 
connection  with  the  disturbed  neural  currents  should  be  looked  for. 
If  there  is  a  state  of  anemia,  or  lack  of  nutrition,  here  may  be  its 
origin.  The  starved  nerves  are  loudly  crying  for  the  sustenance 
they  lack. 

All  these  sources  excluded,  a  neuroma,  or  some  other  disor- 
ganization of  the  nerve  tissue  itself  may  be  suspected.  When 
this  is  the  case  and  a  true  neuralgia  is  indicated,  more  minute  in- 
quiries should  be  made  as  to  the  character  of  the  subjective  symp- 
toms. 

If  neuralgic,  the  pain  will  be  unilateral.  Though  not  local,  it 
will  affect  but  one  side,  for  bilateral  disorders  of  this  kind  are 
something  more  than  rare. 

The  pain  will  usually  follow  the  course  of  the  trunk  of  the  dis- 
turbed nerve.  That  is,  it  may  be  recognized  at  different  points  in 
the  route. 


152  ORAL    PATHOLOGY    AND    PRACTICE. 

It  will  be  sudden  in  its  attack.  Its  onset  will  not  be  a  gradual 
approach,  increasing  in  intensity  until  the  climax  is  reached  and 
then  subsiding  by  degrees,  but,  from  entire  ease,  instantly  the 
victim  is  in  the  throes  of  the  most  agonizing  torture. 

It  will  be  of  a  darting,  stabbing,  boring  character.  It  is  not 
the  steady,  dull,  throbbing,  continuous  pressure  of  a  pus  gather- 
ing. 

It  will  be  markedly  intermittent.  There  will  be  intervals  of 
complete  immunity  of  greater  or  less  length  succeeded  by 
paroxysms  that  will  end  as  suddenly  as  they  begin.  There  may 
or  may  not  be  regularity  in  these  attacks. 

In  the  earlier  stages  there  is  usually  an  increase  in  severity 
with  each  paroxysm,  to  be  succeeded  by  decreasing  violence. 
While  the  invasions  are  sudden  in  their  attack  and  subsidence, 
there  is  a  true  paroxysmal  character  to  their  recurrence,  each  one 
becoming  more  severe  until  the  climax  is  reached,  when  the  abate- 
ment will  be  as  gradual. 

There  is  no  functional  disturbance  connected  with  the  attacks. 
The  pulse  will  not  be  accelerated,  nor  will  the  temperature  rise. 
There  is  no  fever  or  other  general  disturbance.  This  is  an  im- 
portant pathognomonic  symptom. 

In  some  instances,  especially  in  cases  of  long  standing,  there 
will  be  soreness  along  the  track  of  the  affected  nerve.  This  may  be 
especially  marked  at  the  foramen  of  exit.  Anesthetic  spots  in  the 
tissues  supplied  by  the  disordered  nerve  may  assist  in  the  diagnosis. 

Reflex  symptoms  in  communicating  nerves  may  be  exhibited. 
There  may  be  spasms  and  muscular  twitchings.  Tears  may  flow, 
the  effect  of  reflex  irritation,  or  salivary  secretions  may  be  markedly 
increased. 

Fatigue  and  depressing  influences  bring  on  invasions,  or 
exacerbate  them.  The  receipt  of  distressing  news  will  possibly 
provoke  an  attack.  Sleeplessness  or  any  unusually  prolonged 
exertion  will  be  likely  to  be  followed  by  paroxysms. 

The  clinical  history  is  usually  quite  distinct  and  marked. 
Neurotic  persons,  and  those  with  an  unbalanced  nervous  organiza- 
tion, are  especially  liable  to  attacks.  Hence  the  neuralgias  are 
frequently  closely  related  to  hysteria,  migraine  or  sick-headache, 
hypochondria,  paralysis,  catalepsy,  epilepsy,  and  other  nervous  and 
convulsive  disorders.  Clavus  hystericus  is  but  another  special  form 
of  it. 


FACIAL    NEURALGIAS.  153 

It  usually  accompanies  or  indicates  an  atonic,  debilitated  condi- 
tion. It  is  sometimes  among  the  sequelae  of  a  long-continued  fever 
or  other  exhausting  disease. 

It  is  especially  liable  to  attack  those  who  are  suffering  from 
malaria  or  miasmatic  fevers.  In  such  instances  it  sometimes  as- 
sumes the  form  of  "brow  ague." 

The  gouty  and  rheumatic  diathesis  seems  especially  provoca- 
tive of  different  forms  of  neuralgia.  Among  these,  sympathetic 
affections  of  the  trigeminus,  or  fifth  cranial  pair,  are  not  un- 
common. Indeed,  sympathetic  pains  along  the  course  of  com- 
municating branches  or  nerves,  or  through  those  but  secondarily 
connected  by  different  ganglia,  would  naturally  be  anticipated  from 
the  very  nature  of  the  disorder.  It  could  not  well  be  otherwise 
than  that  reflected  pain  would  be  felt  in  perhaps  distant  tissues 
or  organs.  These  may  not  be  of  a  severe  character,  and  they  will 
probably  be  felt  at  the  outset,  or  more  likely  still  at  the  close,  of  a 
paroxysm.  Yet  their  existence  may  be  an  important  part  of  the 
clinical  history,  and  should  be  carefully  sought  out. 

Treatment. 

A  real  neuralgia  having  been  clearly  diagnosed,  the  first  thing 
will  be  to  determine  its  cause  and  to  remove  it.  If  there  is  any 
local  source  of  irritation  it  must  be  remedied. 

The  hygiene  of  neuralgic  patients  should  be  carefully  looked  to. 
They  must  be  guarded  from  sudden  changes  of  temperature, 
draughts  of  cold  air,  etc.  All  sanitary  precautions  must  be 
adopted,  and  if  the  patient  suffers  from  malaria  removal  from  the 
miasmatic  influence  is  the  first  consideration. 

Plenty  of  out-door  exercise  must  be  urged,  with  a  liberal,  rather 
stimulating  diet.  Extreme  fatigue  should  be  guarded  against,  and 
bodily  and  mental  rest  is  important. 

If  there  is  a  constitutional  or  general  functional  dyscrasia,  it 
must  be  relieved.  Nervous  sedatives  may  be  prescribed,  and  gen- 
eral quiet  insisted  upon. 

Potassium  bromide,  ten  grains  in  water,  from  two  to  ten  times 
per  day,  will  be  found  useful,  or  tincture  of  valerian  and  gentian, 
equal  parts  in  teaspoonful  doses.  During  the  paroxysm,  digitalis, 
or  veratrum  viride  in  five-drop  doses  may  be  given,  and  aromatic 
spirits  of  ammonia  in  fifty-drop  doses  will  be  found  useful. 


154  ORAL    PATHOLOGY    AND    PRACTICE. 

If  there  is  a  gouty  diathesis,  wine  of  colchicum  in  small  doses, 
frequently  repeated  if  necessary,  should  be  prescribed. 

Muriate  of  ammonia  fumes,  arising  from  the  burning  of  the 
salt  upon  a  hot  iron  in  the  room,  sometimes  give  gradual  relief. 

If  the  neuralgia  is  of  miasmatic  origin,  from  three  to  ten  grains 
of  quinine  should  be  administered,  or  Fowler's  solution  of  arsenic 
and  potash  in  ten-drop  doses,  two  or  three  times  per  day. 

Hot  moist  applications  to  the  affected  parts  are  very  useful, 
and  massage  sometimes  gives  very  ready  relief,  although  there  are 
instances  in  which  it  will  be  found  exacerbating.  It  must  be 
gentle,  and  not  too  long  continued  at  first. 

If  the  paroxysms  are  very  violent,  it  may  be  necessary  to  allow 
the  patient  to  inhale  the  vapor  of  ether  or  chloroform  for  a  short 
time ;  of  course,  not  to  the  point  of  entire  narcosis. 

If  none  of  the  usual  remedies  are  effective,  and  if  the 
paroxysms  are  violent,  resection  of  the  affected  nerve  may  be 
necessary.  This  will,  with  comparative  frequency,  be  called  for  in 
neuralgia,  especially  in  that  of  the  inferior  dental  nerve.  Pro- 
fessor Brophy,  of  Chicago,  has  greatly  simplified  this  operation,- 
and  by  his  method  it  no  longer  presents  any  formidable  difficulties. 
His  resections  of  the  infra-orbital  from  the  oral  cavity  also  relieves 
that  operation  from  many  complications. 


CHAPTER   XXXIII. 
FACIAL  PARALYSIS. 


In  its  etiology  this  affection  is  closely  connected  with  facial 
neuralgia,  but  it  differs  from  it  in  being  the  effect  of  lack  of  nerve 
nutrition,  while  the  neuralgias  are  more  frequently  the  result  of 
overstimulation.  It  is  also  more  frequently  due  to  organic  lesions 
or  cachectic  conditions.  It  may  arise  from  syphilis,  tubercle  in' 
the  cerebral  centers  or  cord,  or  a  blood  clot  in  the  brain.  In  any 
case,  it  implies  disordered  nerve  function,  and  its  treatment  may 
often  properly  fall  within  the  province  of  the  oral  physician,  inas- 
much as  facial  paralysis  is  not  infrequently  due  to  some  oral  lesion.. 

Facial  paralysis  is  the  complete  inhibition  of  efferent  neural 
currents  in  the  tissues  affected,  with  usually  a  local  anesthesia,  or 
suspension  of  afferent  nerve  currents,  more  or  less  complete.     It  may 


FACIAL    PARALYSIS.  I  55 

be  traumatic  or  idiopathic  in  its  origin.  If  the  former,  there  will 
be  no  difficulty  in  determining  the  fact,  while  in  the  latter  case  its 
source  will  be  more  obscure.  It  may  be  complete  or  incomplete. 
It  is  complete  when  there  is  a  total  loss,  and  incomplete  when  there 
is  only  more  or  less  of  diminution  of  function  in  the  nerves.  It  is 
general  when  there  is  loss  of  power  in  both  the  upper  and  lower 
extremities,  and  local  when  it  is  limited  in  the  number  of  muscles 
affected.  Facial  paralysis  is  local  in  its  character,  and  as  seen  in- 
oral  practice  it  is  usually  but  partial. 

Paralysis  of  sensation  may  be  either  loss  of  tactile  sense — in- 
ability to  receive  impressions  from  external  contact — or  immunity 
to  painful  sensations.  Thus  the  skin  and  the  mucous  membrane 
of  the  mouth  are  endowed  with  both  kinds  of  sensibility.  The 
capacity  of  these  tissues  to  receive  painful  impressions  may  be 
quite  impaired,  or  even  lost,  while  the  tactile  or  feeling  response 
to  external  agents  remains.  But  in  these  instances  the  impression 
made  by  ice,  or  a  hot  iron,  will  not  materially  differ  from  that 
derived  from  a  piece  of  wood. 

Paralysis  of  the  tactile  sense  is  commonly  called  anesthesia, 
while  that  of  the  sense  of  pain  is  denominated  analgesia.  Reflex 
paralysis  is  a  term  that  has  been  applied  to  cases  in  which  a 
paralyzed  condition  of  certain  parts  is  attributed  either  to  a  wound 
or  shock  received  from  other  and  more  or  less  remote  parts,  or  to 
a  local  disease  situated  elsewhere  than  in  the  paralyzed  region.  Dr. 
Brown-Sequard  supposed  this  to  be  induced  through  shock  to  the 
vaso-motor  nerves,  thus  interfering  with  the  nutrition  of  the  nerve 
centers. 

The  instances  of  paralysis  that  are  of  the  greatest  interest  to 
the  dentist  are  those  of  the  fifth  and  the  seventh  pair  of  cranial 
nerves.  The  fifth,  or  trifacial,  is  the  great  sensory  nerve  of  the 
head  and  face  and  the  motor  nerve  of  the  muscles  of  mastication, 
while  the  seventh  is  the  motor  nerve  of  the  muscles  of  expression. 
Complete  paralysis  of  the  fifth  nerve  results  in  the  loss  of  sensibility 
of  one  side  of  the  face,  of  the  mucous  membrane  of  the  mouth,  the 
conjunctival  membrane,  the  anterior  portions  of  the  tongue,  with 
the  muscles  of  mastication  upon  the  affected  side.  The  external 
manifestations  are  not  so  pronounced  as  in  paralysis  of  the  seventh 
nerve,  because  the  resulting  deformity  is  not  so  great.  There  is  a 
loss  of  the  special  sense  of  taste,  and  sensation  is  absent.     But  i/ 


156  ORAL    PATHOLOGY    AND    PRACTICE. 

the  affection  is  unilateral,  mastication  may  be  carried  on  by  the  use 
of  the  muscles  upon  the  sound  side.  The  tongue  and  buccal  tissues 
upon  the  paralyzed  side  are  frequently  bitten  and  lacerated  in 
the  act  of  taking  food,  sometimes  seriously,  because  the  muscles 
are  unable  to  keep  themselves  from  getting  between  the  teeth,  and 
sensation  being  gone  the  patient  is  unaware  of  the  injuries  that  are 
being  received.  Such  paralysis  may  be  induced  by  long  exposure 
of  the  face  to  cold  or  a  keen  wind. 

Paralysis  of  the  seventh  cranial  nerve  is  perhaps  not  so  com- 
mon as  that  of  the  fifth,  but  it  is  much  more  readily  observed,  as  it 
results  in  serious  deformity.  With  the  loss  of  function  in  the  nerve 
all  expression  in  the  affected  side  is  lost.  In  speaking  or  smiling 
the  mouth  is  drawn  toward  the  sound  side  through  the  loss  of  con- 
tractile power  in  the  muscles  of  the  affected  side.  The  contractility 
of  the  orbicularis  oculi  being  absent,  the  patient  is  unable  to  close 
the  eye  or  to  wink.  The  secretions  of  the  lacrymal  gland  are  not 
diffused  over  the  conjunctiva  owing  to  the  loss  of  function  in  the 
orbicularis,  and  there  is  a  more  or  less  constant  overflow  of  tears 
upon  the  cheek.  The  saliva  dribbles  from  the  angle  of  the  mouth, 
and  the  pronunciation  of  certain  letters  of  the  alphabet  is  interfered 
with. 

Paralysis  of  the  seventh  is  perhaps  most  often  caused  by  intra- 
cranial disease.  These  cases  will  properly  fall  within  the  province 
of  the  general  practitioner.  But  it  may  be  the  result  of  injury. 
The  extraction  of  a  considerable  number  of  teeth  at  one  time  may 
produce  a  shock  that  will  cause  spasms  of  the  muscles  of  mastica- 
tion, or  even  inhibition  of  "function  and  paralysis,  with  jaw  drop. 
The  spasm  may  be  clonic  (paroxysmal)  or  tonic  (continuous). 

The  symptoms  are  too  pronounced  to  be  mistaken.  There  will 
be  a  drawing  of  the  muscles  of  the  face,  due  to  their  entire  relaxa- 
tion, with  a  loss  of  mobility.  The  eye  remains  staringly  open,  and 
a  smile  is  observable  on  one  side  alone.  All  expression  upon  the 
affected  side  is  lost  and  the  muscles  are  in  a  state  of  tonic  relaxa- 
tion. This  will  be  observed  by  the  operator  before  the  patient 
becomes  aware  of  the  lesion.  If  it  is  of  a  clonic  character  he  may 
by  gentle  manipulation  of  the  tissues  relieve  the  spasm,  or  tem- 
porary paralysis,  and  within  a  few'  moments  have  the  satisfaction  of 
seeing  the  muscles  regain  their  tone.  Of  course  he  will  remove 
the  hand-glass  from  the  reach  of  the  patient  to  prevent  the  unneces- 


FACIAL    PARALYSIS.  157 

sary  alarm  and  nervousness  which  discovery  would  cause,  and 
which  would  only  tend  to  aggravate  the  condition.  Should  the 
injury  be  more  lasting  in  its  character  and  assume  a  tonic  form,  the 
dentist  should  explain  to  the  patient  the  probably  temporary  nature 
of  the  lesion  and  commence  the  proper  treatment  for  relief  of  the 
condition. 

One  of  the  most  effectual  remedies  for  this  condition  is  elec- 
tricity. The  faradic  or  induced  current  should  ordinarily  be  used, 
and  it  must  be  gentle  at  the  outset,  nor  should  it  be  continued 
too  long.  The  cathode  or  negative  pole  should  be  placed  over  the 
cerebellum,  and  the  anode  or  positive  electrode  carried  gently  over 
the  points  of  distribution  of  the  affected  nerve.  Occasionally  the 
poles  may  be  changed,  and  if  it  is  desired  to  stimulate  the  facial 
nerve  alone,  the  stationary  electrode  may  be  placed  immediately  in 
front  of  the  external  auditory  meatus,  while  the  other  is  moved 
successively  over  the  various  terminal  branches.  This  treatment, 
if  found  beneficial,  may  be  repeated  every  day,  provided  the  cur- 
rent is  not  too  strong  and  not  too  long  continued.  At  the  outset 
it  should  not  be  used  so  often. 

If  the  disorder  has  its  seat  in  the  ganglia,  the  magneto-electric 
interrupted  current  may  sometimes  be  used  with  good  effect,  but  it 
should  be  employed  with  caution,  because  it  may  still  further  tend 
to  the  inhibition  of  the  neural  currents  in  exhausted  trunks  or 
branches. 

Massage  of  paralytic  muscles,  if  mild  and  properly  applied,  will 
be  of  great  benefit  in  many  cases.  The  facial  muscles  may  be  gently 
manipulated  with  the  balls  of  the  fingers,  and  rubbed  in  the  direc- 
tion of  their  fibers  with  the- palm  of  the  hand. 

The  hygienic  condition  must,  of  course,  be  carefully  looked 
after,  and  out-of-door  exercise  with  nourishing  food  directed. 
Vegetable  tonics  may  be  prescribed  if  indicated,  and  quiet  and  rest 
ordered.  If  the  paralysis  is  the  result  of  any  trauma,  such  as  the 
extraction  of  teeth,  the  wounds  must  be  carefully  examined  to  see 
if  there  are  any  loose  fragments  of  alveolus  or  bone  left,  and  all 
possibly  irritating  projections  and  spiculse  should  be  removed.  An 
aseptic  condition  must  be  maintained,  and  soothing  applications 
applied.  With  these  precautions,  unless  the  lesion  is  very  great,  a 
gradual  return  of  functional  activity  may  be  anticipated. 


158  ORAL    PATHOLOGY   AND    PRACTICE. 

CHAPTER  XXXIV. 

SYMPATHETIC  DISTURBANCES. 

The  nervous  system  of  the  body  holds  all  the  various  organs  and 
tissues  in  correlation  with  each  other,  and  secures  harmonious 
functional  action  between  them.  Every  organ  works,  not  alone 
for  itself,  but  for  all  the  rest.  There  is  but  one  heart  to  carry  on 
the  vascular  circulation  for  all  the  tissues,  but  one  digestive  tract  to 
provide  nutrition  for  all,  and  but  one  pulmonary  organ  to  furnish 
the  necessary  supply  of  oxygen.  Hence  the  mutual  interdepend- 
ence is  complete,  and  no  tissue  or  organ  can  be  properly  studied 
aside  from  its  relation  to  the  others.  No  oral  physician,  or  dentist, 
is  equipped  for  the  practice  of  his  specialty  until  he  can  show  that 
he  has  made  himself  acquainted  with  the  functions  of  other  organs, 
and  has  learned  their  possible  reflex  agency  upon  those  with  whose 
care  he  is  especially  charged.  A  fair  knowledge  of  the  anatomy 
and  the  physiological  function  of  every  tissue  in  the  body  is  essen- 
tial to  the  dentist  as  well  as  to  the  general  practitioner,  and  with- 
out the  basal  facts  upon  which  all  curative  measures  must  be 
founded  he  is  as  unfitted  for  his  vocation  as  would  be  any  other 
man  who  professes  to  practice  any  branch  of  the  healing  art.  Any 
■disordered  condition  of  one  organ  affects  to  a  greater  or  less  degree 
all  the  others.  The  sympathy  may  not  be  as  active  in  one  case  as 
in  some  others,  but  it  is  as  certain.  The  dependence  of  one  tissue 
or  organ  upon  another  may  not  be  as  complete  or  entire  as  that  of 
others,  or  as  may  be  the  reciprocal  reliance,  but  it  surely  exists. 
Proper  functional  activity  of  the  brain  may  for  some  years  be 
more  disturbed  by  indigestion  than  would  ensue  to  the  stomach  if 
the  converse  were  the  case,  but  no  physiologist  would  assert  that 
digestion  could  be  properly  and  fully  performed  in  cerebral  conges- 
tion. The  gravid  uterus  of  the  female  will  be  more  deranged  by 
toothache  than  the  teeth  will  be  disturbed  by  metritis,  but  each 
reacts  upon  the  other  to  the  extent  of  its  susceptibility,  and  their 
mutual  relations  cannot  be  lost  to  sight. 

The  organs  disturbed  by  diseases  of  the  teeth  and  the  oral 
tissues  will  be  those  to  which  they  bear  the  closest  relation.  It  is 
well  known  that  the  teeth  sympathize  with  each  other  to  such  an 
extent  that  it  is  sometimes  difficult  to  determine  which  one,  and 


SYMPATHETIC    DISTURBANCES..  I59 

sometimes  which  jaw,  is  affected.  Otitis  media  may  exhibit  itself 
as  toothache,  while  on  the  other  hand  pains  in  the  middle  ear  are 
very  often  mere  reflexes  of  odontalgia.  The  eye  sympathizes  with 
the  teeth  to  such  an  extent  as  sometimes  to  exhibit  a  profuse 
lacrymal  discharge  as  the  accompaniment  of  toothache,  and  alveo- 
lar abscess  may  be  diagnosed  by  the  condition  of  the  pulse.  The 
otologist  especially  should  be  on  good  terms  with  the  dentist,  for 
mutual  consultation  is  frequently  desirable,  owing  to  the  intimate 
relations  of  the  organs  concerned. 

But  the  reflex  disturbances  which  most  concern  both  practi- 
tioner and  patient  are  the  possible  complications  of  pregnancy. 
Women  have  long  been  taught  that  the  relations  between  the  teeth 
and  the  impregnated  uterus  are  so  intimate  that  each  must 
vicariously  suffer  for  the  other.  "For  every  child  a  tooth,"  was  a 
proverb  long  before  the  period  of  modern  dentistry.  That  extrac- 
tion is  very  liable  to  be  followed  by  premature  delivery  is  a  part  of 
the  creed  of  every  expectant  mother.  The  impression  resting  in 
the  minds  of  too  many  dentists  that  temporary  disturbances  may, 
within  a  short  time,  exhibit  themselves  in  a  softened  or  changed 
condition  of  the  tooth  structure,  is  perhaps  responsible  for  a  part 
of  the  general  belief  that  the  teeth  decay  to  a  much  greater  extent 
than  usual  during  pregnancy. 

It  should  be  remembered  that  nutritive  changes  in  the  dentine 
are  exceedingly  slow,  while  it  is  not  unreservedly  admitted  that  they 
take  place  at  all  in  enamel.  Hence,  while  functional  disturbances 
in  the  teeth  are  quick  to  manifest  themselves  in  allied  tissues,  the 
reverse  is  not  the  case.  A  continued  fever  may  cause  a  great  waste 
in  many  tissues,  but  it  cannot  in  the  teeth,  because  there  are  in 
them  no  absorbents,  no  lymph  system.  There  is  no  active  circula- 
tion in  either  dentine  or  enamel,  through  which  progressive  or 
retrogressive  changes  may  be  readily  and  quickly  wrought.  The 
supposed  divergence  of  the  nutrient  currents  from  the  teeth  to  the 
growing  child  must,  then,  be  largely  imaginary,  and  there  can  be 
no  sudden  breaking  down  of  these  organs  during  pregnancy. 

And  yet  the  general  impression  that  the  teeth  decay  more  at 
that  time  than  any  other  doubtless  has  some  basis  upon  which  to 
rest.  One  explanation  may  be  found  in  the  fact  that  at  such  times 
the  pregnant  woman  has  something  else  to  take  up  her  whole  atten- 
tion, and  often  intermits  the  care  that  she  is  accustomed  to  give 


l6o  ORAL    PATHOLOGY    AND    PRACTICE. 

her  teeth.  Food  is  suffered  to  remain  upon  and  between  them,, 
and  fermentation  does  its  perfect  work.  The  pregnant  woman 
sometimes  has  perverted  or  unnatural  appetites,  and  takes  into  her 
mouth  deleterious  substances.  Mineral  tonics  are  frequently  pre- 
scribed for  her,  and  these  may  bring  about  destructive  results. 
But  there  is  little  doubt  that  the  fact  that  at  least  a  year  passes  in 
which  she  is  usually  without  the  dentist's  help  is  the  principal  factor 
in  the  result  attained.  Poor  people,  who  never  care  for  their  teeth,, 
find  little  difference  between  the  period  of  gestation  and  any  other. 

The  fear  that  a  visit  to  the  dentist  must  result  disastrously  is 
a  mistaken  apprehension.  It  is  the  true  office  of  the  oral  practi- 
tioner to  relieve  pain,  and  not  to  cause  it.  Every  woman  who  finds 
herself  pregnant  should  visit  her  dentist,  if  he  is  a  competent  man, 
should  tell  him  her  condition,  and  place  herself  in  his  hands  for 
such  measures  as  are  necessary.  He  will  take  special  care  to  avoid 
giving  her  pain  at  such  a  time,  not  because  it  would  always  be 
immediately  hazardous,  but  from  the  necessity  for  preserving  her 
mental  and  nervous  equilibrium  to  as  great  an  extent  as  is  possible. 
Jf  there  are  cavities  of  decay  that  would  be  likely  to  bring  about 
complications  before  the  time  for  her  delivery,  they  should  be  filled, 
usually  with  plastic  materials.  If  there  are  troublesome  teeth,  so 
badly  diseased  as  to  forbid  conservative  measures,  they  should  be 
promptly  extracted.  If  the  administration  of  a  general  anesthetic 
is  essential,  she  should  be  referred  to  her  medical  attendant.  If 
from  the  performance  of  any  such  necessary  operation,  when  care- 
fully and  skillfully  done,  any  ultimate  harm  has  ever  occurred,  it 
has  not  been  made  a  matter  of  record,  and  the  world  is  in  ignorance 
o :  it.  It  should  not  be  forgotten  that  the  pregnant  female  is  usually 
in  a  state  of  exalted  nervous  sensibility,  but  that  does  not  neces- 
sarily imply  that  all  operations  upon  the  teeth  are  inhibited. 

That  there  is  more  toothache  during  gestation  than  at  other 
times  may  be  quite  true,  but  there  are  often  sympathetic  disturb- 
ances, without  real  tooth  lesions,  that  have  their  origin  in  the 
disordered  nervous  condition.  Concerning  the  nutrition  of  the 
teeth  of  both  mother  and  child,  and  the  prevailing  belief  that  these 
can  be  governed  by  any  specially  regulated  diet,  another  chapter 
will  have  something  to  say. 


DISEASES    OF    TH3:    MAXILLARY    SINUS.  l6l 

CHAPTER     XXXV. 
DISEASES  OF  THE  MAXILLARY  SINUS. 

The  position  and  relations  of  the  Antrum  of  Highmore,  or  the 
Maxillary  Sinus,  make  it  peculiarly  liable  to  disorders  of  a  catarrhal 
nature.  There  doubtless  exist  many  more  such  than  are  recognized 
by  oral  physicians.  The  sinus  is  a  cavity  within  the  superior 
maxilla,  connected  by  a  small  opening  with  the  air  passages  of 
the  nose.  It  allows  proper  contour  of  the  face  without  the  weight 
of  bone  that  would  be  the  consequence  of  solidity.  It  also  makes 
the  nutriment  of  the  bone  more  easy,  and  obviates  any  necessity 
for  a  large  medullary  portion.  But  its  principal  utility  is  in  giving 
resonance  to  the  voice.  All  musical  instruments  have  a  hollow 
chamber  of  some  kind,  to  increase  the  reverberations  and  reflect 
the  vibrations  of  the  air.  The  perfection  of  the  instrument  and  its 
quality  and  volume  of  tone  depend  very  largely  upon  the  particular 
form  of  this  reverberatory  chamber.  Many  years  of  experiment 
have  not  been  able  to  devise  any  beneficial  modification  of  the 
peculiar  shape  of  the  body  of  the  violin,  as  it  was  fashioned  by 
Guarnerius,  more  than  two  hundred  years  ago.  Any  departure 
from  that  model,  whether  accidental  or  intentional,  has  been  found 
to  change  the  character  of  the  vibrations  and  impair  the  tone  of 
the  instrument. 

The  antrum  is  the  principal  sounding-chamber  of  the  human 
voice,  and  the  wide  variations  in  the  character  of  the  tones  produced 
are  due  in  a  large  degree  to  the  size,  shape,  and  condition  of  the 
cavity.  The  howling  monkey,  whose  voice  can  be  heard  at  night 
for  several  miles,  has  an  additional  osseous  chamber  to  reinforce 
the  reverberations  of  the  antrum.  (See  Fig.  42.)  All  are  aware 
of  the  peculiar  hard,  metallic,  unmusical  tone  that  is  communicated 
to  the  voice  in  cases  of  empyema  of  the  antrum,  or  in  atresia  of 
the  communicating  sinus. 

The  size  and  shape  of  the  antrum  in  different  individuals  vary 
as  greatly  as  do  the  characteristics  of  the  voice.  In  some  it  is  large, 
and  occupies  the  whole  center  of  the  bone.  The  two  antra  in  the 
maxillse  have  even  been  known  to  be  a  continuous  cavity,  united 
by  a  communicating  opening  across  the  symphysis.     Usually,  how- 


1 62 


ORAL    PATHOLOGY    AND    PRACTICE. 


ever,  its  anterior  limit  is  the  canine  fossa.  It  is  sometimes  par- 
tially divided  into  a  ntimber  of  chambers  by  septa  passing  across 
its  floors.     (See  Fig.  43.) 

The  opening  by  which  it  communicates  with  the  air  passages  is 
at  the  point  of  junction  of  the  ethmoid  and  palate  bones  and  the 
turbinated  process  of  the  superior  maxilla.  This  is  usually  at  or 
very  near  its  highest  point.  Dr.  M.  H.  Cryer,  of  Philadelphia,  has, 
by  his  dissections  and  studies  of  the  cranial  bones,  added  largely 

Fig.  42. 


Showing  THE  Resonant  Chamber  Attached  to  the  Larynx  in  the  Howling  Monkey. 

to  our  knowledge  of  the  structure  and  configuration  of  this  cavity ; 
and  Dr.  Thomas  Fillebrown,  of  Boston,  has  given  us  yet  further 
illumination. 

The  commencement  of  the  formation  of  this  cavity  is  not  until 
early  childhood  has  been  passed.  Hence  antral  disorders  are  un- 
known in  infancy,  because  there  is  then  no  maxillary  sinus  to 
become  diseased. 

The  imicous  membrane  lining  the  antrum  is  continuous  with 
the  Schneiderian,  or  that  covering  the  bones  and  cartilage  of  the 


DISEASES    OF    THE    MAXILLARY    SINUS. 


163 


nasal  cavity.  It  will  therefore  be  liable  to  the  same  diseases  and 
be  materially  aifected  by  the  condition  of  the  air  passages.  In- 
flammations and  degenerations  of  the  Schneiderian  membrane,  by 
mere  continuity  may  be  communicated  to  the  antrum,  and  a  nasal 
catarrh  may  induce  a  chronic  antral  disorder.  This  will  be  the 
most  fruitful  source  of  the  degenerated  conditions  so  often  present, 
and  if  what  has  frequently  been  asserted  is  true,  that  in  the  northern 
and  eastern  parts  of  the  United  States  the  person  who  is  entirely 
free  from  catarrhal  troubles  is  an  exception,  it  must  necessarily 

Fig.  43. 


Vertical  Section  through  the  Skull. 

a,  Frontal  sinus ;  6,  A  wire  probe  thrust  into  the  infundibulum  ;  c  and  e,  Membranous 
septa  extending  across  the  antra  ;  d,  The  oral  cavity. 

follow  that  most  of  the  residents  of  those  seci-ions  have  disor- 
dered or  inflamed  antra,  and  this  may  account  for  the  nasal  tone 
said  to  be  characteristic  of  their  voices. 

The  roots  of  decayed  and  devitalized  teeth  may  sometimes 
penetrate  the  floor  of  this  cavity  and  become  points  of  irritation  and 
of  infection.  It  does  not  seem  probable  that  any  healthy  root  can 
actually  pierce  the  floor.  The  very  conditions  of  the  formation  of 
the  apex  demand  its  investment  by  the  pericementum,  and  that 
being  a  double  membrane  its  functional  activity  implies  a  septum 


164  ORAL   PATHOLOGY   AND    PRACTICE. 

o£  bone  upon  its  exterior  surface.  Accordingly,  in  the  examina- 
tion of  antra  it  is  found  that  the  apex  of  the  root  of  a  premolar  or 
molar  tooth  that  might  otherwise  be  within  the  cavity  is  covered 
with  a  thin  septum  of  bone  that  forms  a  distinct  eminence  upon  the 
floor,  and  no  tooth  that  reaches  the  level  of  the  antral  floor  is  with- 
out this.  When,  however,  there  is  a  devitalization  of  the  pulp, 
with  a  consequent  pericemental  inflammation  at  the  apex,  the 
nature  of  that  affection  implies  an  absorption  of  the  bone  that  forms 
the  septum;  and  then  the  end  of  the  tooth  might  be  within  the 
antral  walls,  perhaps  perforating  the  mucous  membrane.  Under 
such  circumstances  the  apical  pericementum  would  be  lost,  and  the 
root  to  that  extent  denuded. 

If  an  abscess  forms  at  the  apex,  it  may  discharge  into  the  sinus, 
but  such  a  condition  will  not  be  likely  to  exist,  because  there  must  be 
investing  tissues  capable  of  affording  a  continuous  supply  of  plastic 
lymph  to  form  the  basis  of  the  pus  discharge.  As  this  would  not 
be  the  case  when  the  apex  of  the  root  actually  lay  within  the 
antrum,  penetrating  the  lining,  a  chronic  abscess  discharging  into 
the  antrum  is  not  probable.  The  projecting  root,  however,  could 
undoubtedly  prove  a  continuous  source  of  irritation  to  the  lining 
membrane,  and  thus  be  the  cause  of  a  persistent  inflammation, 
which  in  due  process  of  time  would  induce  a  condition  of  degenera- 
tion of  the  mucous  follicles,  with  ultimate  breaking  down  of  their 
structure.  In  this  manner  the  roots  of  dead  teeth  may  undoubtedly 
be  the  cause  of  actual  empyema. 

Traumatism  is,  probably,  more  frequently  than  many  persons 
are  aware  of,  the  origin  of  actual  degenerations.  Teeth  are  too 
often  extracted  with  a  degree  of  violence  that  would  never  be  con- 
doned in  the  general  surgeon.  The  fact  that  the  alveolar  walls  are 
exceedingly  vascular,  and  that  injuries  are  healed  more  readily 
than  in  any  other  osseous  tissue,  alone  saves  the  patients  of  many 
harsh  dentists  from  most  serious  consequences.  There  are  more 
fractures  of  alveolar  walls,  even  to  the  depth  of  the  maxillary  sinus, 
than  most  people  would  imagine.  There  are  few  practitioners  who 
have  not  seen  cases,  either  in  their  own  practice  or  that  of  others, 
in  which  a  part  or  the  whole  of  the  septa  of  the  molar  teeth  was 
removed,  making  a  considerable  opening  into  the  antrum. 

The  presence  of  foreign  substances  sometimes  induces  a  dis- 
eased condition.     Into  a  cavity,  accidentally  made,  may  penetrate 


DISEASES    OF    THE    MAXILLARY    SINUS. 


l6: 


some  extraneous  matter  that  will  remain  a  source  of  irritation,  cr 
the  root  of  a  tooth  may  be  forced  into  a  cavity  in  extraction,  and 
as  long  as  this  remains  the  degeneration  will  be  kept  up. 

It  has  been  demonstrated  that  the  infundibulum,  through 
which  the  frontal  sinus  discharges  its  secretions,  in  a  considerable 
number  of  instances  at  least,  opens  into  the  apex  of  the  antrum 
instead  of  into  the  meatus  of  the  nose.     Normally,  the  opening  is 

Fig.  ^4. 


f\j.^&y\h^,.^ 


Vertical  Section  through  the  Skui.l  Immediately  Posterior  to  that  Shown  in 

Fig.   43. 
a  fli,  Wire  probes  thrust  through  the  natural  apertures  into  the  antrum;  b,  Nasal  fossa 
showing  turbinated  bones  ;  c,  Oral  cavity. 

separated  from  the  mouth  of  the  infundibulum  by  such  a  thin 
septum  that  it  is  readily  broken  down  by  any  diseased  condition. 
In  such  instances  any  vicious  secretions  from  the  frontal  sinus 
v/ould  form  the  initial  point  for  degenerations  in  the  antrum.  (See 
Fig.  44.) 

Whatever  their  source  of  origin,  the  usual  phenomena  pre- 
sented by  antral  diseases  are  those  of  disordered  mucous  membrane. 
The    probable    steps    in    the    degenerative    process    are,    first,    a 


1 66  ORAL    PATHOLOGY    AND    PRACTICE. 

hyperemia,  to  be  succeeded  by  congestion  and  suppression  of  the 
mucous  secretion.  Then  follows  an  active  state  of  inflammation, 
with  degeneration  of  the  mucoid  follicles,  and  perhaps  a  profuse 
watery  discharge.  This  may  continue  for  a  time,  when,  if  the  irri- 
tation is  continued,  further  degeneration  takes  place,  with  final 
breaking  down  or  ulceration  of  the  surfaces.  The  mucous  mem- 
brane thus  destroyed,  and  the  periosteum  devitalized,  there  is  no 
longer  normal  nutrition  for  the  bone,  and  a  progressive  caries  of 
this  tissue,  or  even  necrosis,  with  a  profuse  discharge  of  pus,  will  be 

the  consequence. 

Symptomatology. 

The  symptoms  attending  the  early  stages  of  catarrh  of  the 
antrum  are  not  very  marked  or  distinctive.  There  will  be  a  feeling 
of  dryness,  with  its  characteristic  pain  in  the  antral  region,  and 
possible  pressure.  The  latter  symptom,  however,  more  distinc- 
tively belongs  to  a  later  period.  The  general  phenomena  are  those 
of  catarrh  of  the  air  passages. 

These  are  perhaps  succeeded  by  profuse  watery  secretions, 
which  may  quite  fill  the  antral  cavity  and  produce  that  feeling  of 
pressure  and  the  changes  of  voice  that  are  so  often  observed  in 
acute  coryza.  This  will  pass  away  with  the  other  prodromata  of 
empyema. 

Finally,  the  repeated  attacks  of  the  acute  inflammatory  process 
are  succeeded  by  a  continuous,  chronic  condition,  and  function  is 
permanently  impaired.  This  leads  to  structural  degenerations  in 
the  mucous  follicles  themselves ;  they  break  down  and  an  ulcer- 
ative surface  succeeds,  and  thus  an  empyema  is  established.  Pus 
may  be  formed  in  such  quantities  that  the  antrum  is  filled,  with 
complete  atresia  of  the  natural  opening,  and  a  distressing  distention 
is  the  result. 

The  feeling  of  pressure  under  such  conditions  will  be  severe. 
There  will  be  the  usual  septic  fever,  and  the  superincumbent  tis- 
sues will  be  hot  and  irritable.  If  this  breaking  down  of  the  tissue 
and  the  formation  of  pus  continues,  there  will  be  dilatation  and  pro- 
trusion of  the  antral  walls  at  their  weakest  point.  This  may  be  in 
the  orbital  region,  and  the  eye  may  be  actually  forced  partly  out  of 
its  socket.  It  may  be  at  the  basal  walls,  in  which  case  the  pro- 
trusion will  be  above  the  roots  of  the  teeth;  or  it  may  be  at  the 
palatal  processes  of  the  maxillary,  and  the  protuberance  be  into  the 
oral  cavity. 


TREATMENT    OF   DISEASES    OF    THE    MAXILLARY    SINUS.  167 

The  general  symptoms  will  be  nearly  the  same  if  the  origin 
of  the  disorder  is  other  than  that  of  nasal  catarrh.  If  the  frontal 
sinus  is  diseased,  and  its  depraved  contents  are  discharged  into  the 
antrum  through  a  misdirected  infundibulum,  the  prodromata  will 
be  more  brief  in  their  course,  but  the  pathological  changes  will  not 
materially  differ.  The  same  may  be  said  of  the  presence  of  foreign 
substances  in  the  sinus.  The  character  of  the  changes  will  be  those 
that  are  usual  in  inflammations  of  mucoid  surfaces. 


CHAPTER  XXXVI. 

TREATMENT  OF  DISEASES  OF  THE  MAXILLARY  SINUS. 

The  prognosis  is  usually  good,  provided  all  sources  of  irritation 
can  he  removed,  and,  as  in  all  inflammatory  processes,  the  first 
attention  should  he  paid  to  this  point.  If  the  trouble  is  taken  in  its 
early  stages  of  simple  catarrhal  inflammation,  the  usual  remedies 
for  that  affection  should  be  employed.  Nasal  douches  of 
erethymol,  listerine,  or  borolyptol,  diluted  with  from  three  to  five 
volumes  of  water,  may  be  frequently  used  for  irrigating  the  nasal 
mucous  membrane.  If  these  cause  pain,  a  little  cocain  may  be 
added.  For  the  ordinary  colds,  that  seem  likely  to  run  a  chronic 
course,  with  first  a  dry,  heated  condition  of  the  mucous  membrane, 
followed  by  a  muco-purulent  discharge,  the  following  may  be  used : 

5 — Borolyptol,  ■      oj; 
Cocainas  hydrochlor.,  gr.  ij ; 

Aquae  dest.,  oiij. 

Sig. — Use  as  an  irrigating  douche. 

In  the  acute  stage  of  coryza  the  following  will  be  found  useful: 

5 — Acid,  carbolici,  Z%; 

Alcoholis,  3ij; 

Aq.  ammonise  fort.,  3j; 

Listerine,  oiij. 

Sig. — Pour  half  a  teaspoonful  into  a  cone  made  of  blotting-paper  and 
inhale. 

In  addition,  for  the  relief  of  the  antral  congestion,  a  saline 
cathartic  may  be  given,  its  operation  to  be  followed  at  bed-time  by 
one-sixth  to  a  quarter  of  a  grain  of  sulphate  of  morphia,  dissolved 
in  an  ounce  of  acetate  of  ammonia  liquor. 

With  relief  for  the  catarrhal  inflammation  the  antral  complica- 


l68  ORAL    PATHOLOGY   AND    PRACTICE. 

tion  will  pass  away.  But  if  there  is  any  filling  up  of  the  sinus, 
either  hydromatous  or  empyemic,  it  must  be  opened.  This  is 
accomplished  by  penetrating  the  walls  with  a  trocar.  To'  obtain 
perfect  drainage  it  is  absolutely  essential  that  this  be  done  at  the 
correct  point,  otherwise  some  of  the  cavity  will  continue  to  be 
bathed  in  the  vitiated  fluid.  Usually  the  lowest  depression  is  found 
just  anterior  to  the  first  molar  tooth,  but  this  is  by  no  means 
universally  the  case.  Sometimes  the  antral  cavity  does  not  reach 
anterior  to  this,  and  occasionally  it  lies  considerably  farther  for- 
ward. If  the  thumb  and  finger  are  made  to  grasp  the  alveolar  and 
palatal  processes,  and  the  oral  region  thus  carefully  examined,  one 
may  be  able  to  determine  the  point  at  which  the  divergence  of  the 
walls  marks  the  beginning  of  the  cavity. 

If  the  first  permanent  molar  has  been  removed,  the  best  place 
for  making  an  opening  will  be  at  that  point.  If  it  be  much  decayed 
it  will  be  wise  to  extract  it  and  drill  or  puncture  through  the  socket 
of  its  lingual  root,  as  the  floor  of  the  antrum  is  lower  on  the  lingual 
than  on  the  buccal  side.  Care  must  be  taken  to  avoid  following  too 
far  in  the  direction  of  the  root  if  it  diverge  much  from  the  others. 
The  drill,  or  trocar,  should  be  pointed  in  the  proper  line.  The  best 
instrument  is  a  twist  drill  in  the  dental  engine.  The  cavity  once 
reached,  the  aperture  should  be  expanded  with  a  reamer  until  it  is 
at  least  as  large  as  a  common  lead  pencil.  An  opening  less  than 
this  will  be  likely  to  become  closed.  It  is  not  usually  a  formidable 
operation,  or  one  attended  with  a  great  deal  of  pain,  but  in  most 
instances  it  will  be  advisable  to  administer  an  anesthetic. 

The  opening  once  made,  a  little  time  should  be  given  for  its 
drainage,  when  it  may  be  washed  out  with  tepid  water  in  which 
a  little  salt  has  been  dissolved,  thrown  into  the  cavity  with  a 
syringe.  This  may  be  repeated  until  the  cavity  is  quite  clean,  when 
a  disinfectant,  like  peroxide  of  hydrogen  or  electrozone,  warmed 
to  blood  temperature,  may  be  substituted.  Care  should  be  taken 
to  dilute  it  if  peroxide  of  hydrogen  is  used,  for  if  much  pus  remains, 
and  it  be  injected  pure,  or  nearly  so,  violent  and  painful  foaming 
may  be  the  result. 

If  the  opening  is  of  sufficient  caliber  and  made  at  the  lowest 
point  very  little  treatment  will,  in  cases  uncomplicated  with  dis- 
charges from  the  frontal  sinus  or  foreign  growths  or  substances,  be 
demanded.     The  antrum  should  be  thoroughly  washed  out  with 


TREATMENT   OF   DISEASES   OF   THE    MAXILLARY    SINUS.  l6g- 

tepid  water  before  medicinal  agents  are  introduced.  A  disinfectant 
simply  decomposes  septic  matter,  and  there  is  necessarily  nothing 
therapeutic  in  its  nature  aside  from  this.  It  is  better  to  wash  out 
the  pus  than  to  decompose  it,  for  its  elimination  will  be  more  per- 
fect and  more  readily  brought  about,  provided  the  opening  is  com- 
pletely patulous. 

The  cavity  having  been  cleansed,  the  next  step  will  be  to  secure 
continual  drainage.  For  this  purpose  the  insertion  of  a  drainage 
tube  has  been  recommended,  but  this,  it  is  believed,  will  seldom  be 
found  necessary,  and  there  are  conclusive  reasons  for  its  rejection, 
if  that  be  possible. 

The  drainage  tube  that  has  usually  been  employed  is  of  metal,, 
and  is  attached  to  some  convenient  tooth  by  a  clasp.  It  is  very  diffi- 
cult to  retain  in  position  one  of  any  other  kind,  because  adhesive 
plaster  bandages,  and  the  methods  by  which  such  are  usually  held, 
are  inadmissible  in  the  mouth.  A  metal  drainage  tube  must  of 
necessity  act  as  a  continual  irritant  and  become  a  focus  of  inflam- 
mation and  of  infection.  It  is  almost  impossible  accurately  to 
adjust  its  length,  and  if  it  should  once  be  perfectly  adapted  it  will 
not  remain  so.  If  the  upper  end  projects  above  the  floor  of  the 
antrum  it  will  not  afford  perfect  drainage,  and  if  it  does  not  it  will 
fill  and  become  stopped  with  granulations  more  readily  than  an 
opening  without  such  a  tube,  because  its  irritant  presence  will 
stimulate  hyperplastic  growths. 

It  will  seldom  be  the  case  that  a  drainage  tube  will  be  needed 
if  the  opening  is  sufficient.  Should  the  mouth  of  it  not  remain 
patulous,  the  granulations  should  be  cauterized  or  cut  away.  This 
will  be  better  for  the  disorder  than  to  allow  them  to  grow  about  a 
drainage  tube.  If  the  orifice  is  kept  dehiscent,  open  and  gaping,, 
the  drainage  will  remain  perfect,  and  the  diseased  condition  will 
not  be  perpetuated  by  retention  and  further  degeneration  of  the 
septic  product,  even  for  an  hour. 

Tents  and  plugs  for  the  perforation  should  be  avoided.  They 
are  an  irritation,  retaining  within  the  antrum  the  septic  products 
that  should  be  removed  or  allowed  to  escape  as  soon  as  formed. 
Even  a  moment's  restraint  is  evil  in  its  tendency.  The  sole  excuse 
for  their  employment  is  that  they  prevent  the  entrance  of  food, 
saliva,  etc.,  from  the  mouth.  There  is  no  cause  for  anxiety  from 
this  source,  for  saliva  will  not  enter  against  the  force  of  gravitation,. 


I/O  ORAL    PATHOLOGY   AND    PRACTICE. 

while  food  and  debris  can  only  penetrate  when  forced  in,  and  they 
are  usually  spontaneously  eliminated  before  fermentation  can  take 
place.  But  even  if  there  is  a  liability  to  the  intrusion  of  foreign 
matter  through  an  unstopped  orifice,  the  possible  resulting  injury 
could  not  be  as  great  as  that  arising  from  an  impeded  drainage.  If 
the  natural  foramen  of  the  antrum  is  closed  the  artificial  opening 
m.ust  be  kept  unstopped,  because  communication  with  the  outside 
air  is  a  necessity.  As  well  might  one  seal  up  the  drum-hole  as 
entirely  to  close  the  antrum,  which,  as  has  already  been  said,  is  a 
reverberatory  chamber. 

The  employment  of  tents  and  plugs  has  resulted  in  very  serious 
injury  at  times.  It  will  doubtless  have  been  found  by  most  oral 
surgeons  who  have  had  a  considerable  experience  in  the  treatment 
of  antral  disorders,  that  the  most  obstinate  and  incurable  cases  were 
those  in  which  a  comparatively  small  aperture  had  been  made,  with 
the  subsequent  attempt  to  keep  it  open  by  tents,  distenders,  and 
drainage  tubes.  It  has  become  the  common  usage  of  those  who 
have  acquired  skill  by  extensive  practice  in  these  cases,  first  of  all, 
carefully  to  explore  the  antrum  for  lost  plugs  and  dressings,  or 
parts  of  such,  which  are  certain  to  perpetuate  the  disease.  Any 
oral  surgeon  can  call  to  mind  more  than  one  instance  of  this.  The 
author  has  never  met  with  a  case  of  persistent  antral  degeneration, 
in  which  it  was  possible  to  remove  the  source  of  irritation,  which 
was  not  healed  with  comparative  readiness  if  drainage  was  left  free 
and  unimpeded.  He  has  frequently  met  instances  in  which  no 
lelief  was  obtained  until  a  dressing  or  other  foreign  substance  that 
had  lodged  in  some  depression  in  the  floor  had  been  found  and 
removed.  In  one  case  it  was  a  piece  of  iodoform  gauze  more  than 
six  inches  in  length. 

Perfect  drainage  having  been  secured,  there  are  comparatively 
few  cases  that  will  demand  anything  more.  The  use  of  the  drastic 
and  irritating  remedies  and  solutions  that  are  so  frequently  injected 
is  to  be  avoided.  Cleanliness  once  assured,  the  vis  medicatrix 
natures  will  usually  do  the  rest.  A  considerable  number  of  in- 
stances from  daily  practice  might  here  be  cited,  in  which  a  profuse, 
long-continued,  and  exhausting  empyemic  discharge  was  entirely 
cured  by  a  proper  operation,  the  permanent  removal  of  all  tubes, 
plugs,  tents  and  dressings,  and  a  thorough  washing  out  and  disin- 
fection of  the  sinus. 


TREATMENT   OF    DISEASES    OF    THE    MAXILLARY    SINUS.  I7I 

The  irregularities  in  the  shape  of  some  antra  insure  the  in- 
definite continuance  of  the  septic  state  unless  some  further  surgical 
interference  than  the  mere  perforation  of  the  floor  is  provided. 

Occasionally  septa  will  be  found  crossing  the  cavity,  and  dividing 
it  into  partially  separate  chambers.  Depressions  in  the  base  will 
be  encountered,  which  will  retain  septic  matter.  If  the  opening 
has  been  made  sufficiently  large,  a  bent  silver  probe  may  be  used 
to  explore  for  any  laminae  and  dividing  walls,  and  for  intrusive 
foreign  substances.  When  their  nature  will  permit,  any  septa 
should  be  broken  down,  and  when  this  is  not  practicable  the  patient 
should  be  directed  occasionally  to  incline  the  head  in  such  a  man- 
ner that  any  retained  fluids  may  flow  out  toward  the  drainage  open- 
ing. Care  should  also  be  used  frequently  to  wash  out  such  depres- 
sions and  partial  chambers,  and  to  keep  them  thoroughly  disin- 
fected.    (See  Fig.  43.) 

The  author  has  in  some  instances  found  it  impracticable  to 
make  an  opening  sufifiicient  for  all  this  work  through  the  floor  of  the 
antrum,  and  has  broken  down  the  external  walls  until  the  end  of 
the  finger  could  be  introduced  for  exploratory  purposes.  Such  an 
aperture  gives  entire  access  to  every  part  of  the  sinus,  and  enables 
the  operator  to  determine  the  presence  of  necrosed  conditions,  and 
to  extirpate  dead  tissue,  if  it  be  not  of  too  great  proportions. 
General  surgeons  usually  open  through  the  alveolar  walls  just 
posterior  to  the  canine  fossa,  claiming  that  an  orifice  sufficient  in 
size  cannot  well  be  obtained  at  any  other  point. 

There  will  be  instances  in  which,  from  a  general  atonic  or 
anemic  state,  some  cachectic  condition,  or  special  degeneration  like 
necrosis,  there  is  not  a  speedy  return  to  health.  The  inflammation 
may  assume  a  low,  subacute,  or  chronic  stage,  and  the  indolent 
tissues  refuse  to  respond  to  the  treatment  indicated.  In  such  cases 
more  rigorous  measures  must  be  inaugurated.  After  disinfection 
a  solution  of  three  to  five  grains  of  chloride  of  zinc  to  the  ounce  of 
water  may  be  injected,  and  made  to  reach  every  part.  This  will 
act  as  an  antiseptic  and  a  stimulating  astringent,  and  probably 
bring  about  an  altered  condition.  If  it  be  insufficient,  it  may  be 
used  in  still  stronger  proportions,  the  production  of  painful  and 
irritating  symptoms  being  the  guide  for  its  limitation. 

If  there  is  pain,  it  may  be  treated  by  an  injection  of  dilute 
wine  of  opiurn.     In  case  of  a  profuse  discharge  from  an  ulcerated 


1/2  ORAL    PATHOLOGY   AND   PRACTICE. 

mucous  membrane,  a  solution  of  zinc  sulphate,  one  dram  to  the 
ounce  of  water,  may  be  used.  When  there  is  a  great  deal  of  fetor 
a  solution  of  potassium  permanganate,  ten  grains  to  the  ounce 
of  water,  will  be  found  useful.  '  Carbolized  solutions  may  be 
employed,  the  avowed  aim  being  to  produce  a  temporary  aggrava- 
tion of  the  inflammatory  symptoms,  or  to  change  the  chronic  con- 
dition to  one  that  is  more  acute. 

If  the  degenerative  process  shall  have  proceeded  so  far  as  to 
involve  the  bony  walls,  an  operation  for  the  removal  of  the  dead 
tissue  will  be  necessary.  These  necrosed  conditions  may  be  de- 
tected not  only  by  the  amount  and  character  of  the  pus,  but  the 
condition  can  be  verified  by  careful  explorations  with  the  probe. 
Whenever  the  symptoms  lead  to  the  conclusion  that  depraved  secre- 
tions from  the  frontal  sinus  are  discharged  into  the  antrum,  the 
opening  should  be  kept  patulous  and  the  attention  directed  toward 
the  other  cavity  that  is  the  source  of  the  disease. 

An  opening  through  the  bone  of  considerable  size,  that  has 
served  for  the  drainage  of  pus,  will  not  always  entirely  close.  This 
will  not  materially  matter,  because  there  will  usually  be  a  formation 
of  soft  tissue  and  mucous  membrane  over  it  that  will  be  sufficient 
for  the  exclusion  of  foreign  matter.  Even  if  this  is  not  accom- 
plished little  inconvenience  is  experienced,  provided  nothing  is 
kept  in  it  that  can  retain  food  until  it  ferments  within  the  sinus. 
It  will  not  be  in  a  worse  condition  than  are  the  nasal  passages  in 
cases  of  cleft  palate.  It  may  be  necessary  periodically  to  wash  out 
the  antrum,  but  this  can  readily  and  easily  be  accomplished. 


CHAPTER  XXXVII. 

DISEASES  OF  THE  FRONTAL  SINUS. 

As  this  cavity  is  much  smaller  than  that  of  the  antrum,  and  as 
sometimes  it  is  practically  absent,  its  pathological  complications  are 
less  in  number  and  of  smaller  import.  It  is  another  of  the  openings 
connected  with  the  air  passages,  and  the  reasons  for  its  existence 
are  identical,  though  of  less  importance,  than  in  the  case  of  the 
maxillary  sinus.  As  in  the  case  of  all  other  open  cavities  it  is  lined 
with  mucous  membrane,  and  its  diseases  will  be  the  same  as  those 


DISEASES   OF   THE    FRONTAL    SINUS. 


173 


of  the  antrum,  except  as  they  are  modified  by  the  different  environ- 
ments. It  is  probable  that  they  seldom  originate  in  the  sinus  itself. 
Inflammations  and  degenerations  of  the  lining  membrane  will 
comprise  the  most  of  these,  and,  while  the  presence  of  foreign  sub- 
stances may  be  eliminated  from  the  Hst  of  causes  inducing  them, 
the  pathological  changes  will  be  so  nearly  analogous  that  a 
recapitulation  of  them  is  unnecessary.  In  edemas  and  empyemas 
the  discharge  is  through  the  infundibulum  that  penetrates  the 
ethmoid,  and  into  the  middle  meatus  of  the  nose.     (See  Fig.  45.) 

Fig.  45. 


Vertical  Section  of  the  Skull. 
a,  The  inferior  and  middle  turbinated  processes,    b.  Posterior  part  of  the  antral  or  maxil- 
lary sinus,    c,  The  infundibulum  of  the  ethmoid. 

The  diagnosis  of  these  conditions  must  be  through  the  tracing  of 
this  vitiated  matter  to  its  source,  and  from  the  sense  of  fullness 
and  pressure  that  will  inevitably  be  felt  in  the  supra-orbital  region. 
Local  treatment  will  be  impossible  unless  an  opening  is  made, 
which  will  be  from  the  lower  border  of  the  bone,  through  the 
supra-orbital  prominence  or  ridge  into  the  cavity,  where  it  may  be 
treated  as  in  the  case  of  the  antrum.  But  this  is  a  very  unusual 
operation,  and  seldom  called  for  except  in  cases  of  atresia  of  the 


174  ORAL    PATHOLOGY    AND    PRACTICE. 

discharging  duct  or  canal,  or  when  the  discharge  has  induced  a 
degenerated  condition  of  the  infundibulum,  or  is  flowing  into  the 
maxillary  sinus. 

That  these  latter  conditions  may  exist  and  may  induce  serious 
complications,  the  following  case  in  the  practice  of  Prof.  Truman 
W.  Brophy  amply  demonstrates.  Miss  A.  had  for  some  years 
suffered  from  what  was  pronounced  antral  disease.  Five  opera- 
tions for  its  relief  had  been  made  by  different  surgeons,  most  of 
them  consisting  of  the  usual  opening  and  flushing  of  the  sinus  with 
antiseptic  and  stimulating  solutions.  It  was  now  determined  to 
explore  the  cavity  more  completely  than  had  yet  been  done,  and  to 
this  end  the  maxillary  walls  above  the  roots  of  the  teeth  were 
removed  until  the  finger  could  be  introduced.  No  foreign  sub- 
stance or  growth  was  found,  and  the  cavity  was  temporarily  packed 
with  antiseptic  gauze.  At  a  subsequent  visit  this  was  removed  and 
the  antrum  critically  examined.  Near  the  apex  purulent  matter 
from  some  superior  source  was  observed  to  percolate  initO'  the  sinus. 
The  connection  of  the  frontal  sinus  with  the  diseased  condition 
had  not  previously  been  suspected,  but  in  the  light  of  the  then 
newly  published  obsei*vationis  of  Dr.  Cryer  it  was  at  once  apparent. 
The  infundibulum  was  discharging  pus  into  the  antrum,  and  the 
seat  of  the  disease  was  either  in  the  frontal  sinus  or  in  the  ethmoid,, 
and  a  further  operation  was  at  once  determined  upon.  At  the 
proper  time  the  supra-orbital  tissues  were  divided,  the  filaments 
of  the  supra-orbital  nerve  dissected  out  and  an  opening  made  into 
the  frontal  sinus,  from  which  pus  at  once  welled  up.  The  opening 
was  now  extended  the  whole  length  of  the  sinus,  until  a  probe 
could  be  thrust  down  through  the  infundibulum  for  a  considerable 
distance,  when  its  point  was  found  in  the  maxillary  sinus.  Careful 
probing  now  demonstrated  that  the  cells  of  the  ethmoid  were  in  a 
degenerated  condition,  and  that  the  connecting  passage  was  for  a 
part  of  its  length  devoid  of  its  membranous  lining.  With  properly 
shaped  burs  in  the  surgical  engine  the  incision  was  carried  along 
the  course  of  the  infundibulum  until  the  center  of  the  nasal  bone 
was  reached.  A  considerable  opening  was  made  in  this  bone,  the 
degenerated  portions  of  the  ethmoid  were  removed,  the  surfaces 
of  the  discharging  canal  freshened  and  its  mouth  made  tO'  open  into 
the  nasal  meatus  instead  of  into  the  antrum.  A  drainage  tube  was 
now  inserted  into  the  frontal  sinus,  through  which  the  whole  terri- 


CYSTS    AND    THEIR    TREATMENT.  1 75 

tory  could  be  flushed,  and  the  wound  was  closed  about  it.  The  dis- 
charge was  for  some  time  very  profuse,  but  continued  antiseptic 
treatment  finally  resulted  in  a  complete  cure.  When  the  infundib- 
ulum  was  made  to  discharge  into  the  nasal  cavity  the  trouble  in 
the  antrum  was  at  once  relieved,  and  never  returned,  thus  conclu- 
sively proving  that  the  source  of  disease  was  not  in  this  sinus, 
which  was  only  secondarily  affected  from  the  frontal  sinus. 


CHAPTER    XXXVIII. 
CYSTS  AND  THEIR  TREATMENT. 

A  Cyst  is  a  tumor  containing  a  cavity  or  cavities  filled  with 
fluid  or  semi-fluid  contents.  In  one  ^ense,  it  is  nature's  method  of 
isolating  from  the  tissues  any  foreign  or  irritating  matter.  It  is 
the  only  way  in  which  extraneous  substances  can  be  permitted 
permanently  to  remain  in  the  animal  economy. 

When  cysts  consist  of  a  single  chamber  they  are  simple,  and 
when  divided  by  membranous  septa  multilocular.  Should  they 
contain  teeth  they  are  called  dentigerous  cysts.      (See  Fig.  46.) 

A  cyst  may  also  be  the  result  of  the  stoppage  of  some  duct, 
and  the  consequent  retention  of  the  secretion  of  the  gland  of  which 
it  was  the  discharging  canal;  or  it  may  be  the  mere  collecting  of  a 
watery  fluid  in  a  previously  existing  serous  cavity,  the  outcome  of 
functional  disturbance. 

The  most  common  and  at  the  same  time  the  most  benign  and 
innocent  of  these  tumors  is  the  sebaceous  cyst,  which,  as  its  name 
indicates,  is  filled  with  fatty  matter.     They  vary  in  size  from  that_ 
of  a  millet  seed  to  that  of  an  orange,  and  are  most  frequently  con- 
nected with  the  sebaceous  glands  of  the  skin. 

A  cyst  consists  of  a  membranous  pouch,  without  an  opening, 
that  envelopes  the  alien  substance  when  such  exists,  and  separates 
it  from  the  tissues.  In  like  manner  a  colony  of  bees,  when  some 
animal  or  offensive  substance  which  they  are  unable  to  expel  gains 
entrance  to  the  hive,  seal  it  up  and  segregate  it  by  covering  it  with 
an  impenetrable  coating  of  wax,  within  which  it  loses  its  repulsive- 
ness.     A  cyst  is  filled  with  a  fluid  in  which  the  offending  matter 


176 


ORAL    PATHOLOGY   AND    PRACTICE, 


■floats  or  is  contained,  thus  preventing  its  immediate  contact  even 
with  the  cyst  walls. 

Cysts  are  developed  in  natural  cavities  of  the  body,  or  within 
the  substance  of  an  organ.  They  cause  a  distention  that  with  the 
continual  gathering  of  the  cystic  fluid  and  the  constant  growth  of 
the  cyst  sometimes  becomes  of  enormous  proportions.  It  is  only 
through  their  expansion  that  they  assume  any  dangerous  character, 
for  they  do  not  otherwise  cause  functional  disturbances.     They 

Fig.  46. 


i        \         A*   ^.'     ^  t     J   f 


■/*:rT^^. 


^^^^:!iJ::0^ 


Dentigerous   Cyst  in  a  Young  Horse,  containing    Nearly  a  Quart  of   Denticles. 
a,  Mass  attached  to  the  bone,    b  and  6^,  Loose  pieces.     (From  a  specimen  in  Buffalo 
■College  Museum.) 

may  readily  be  distinguished,  in  most  instances,  through  this 
peculiarity,  and  through  their  slow  formation  and  the  entire  lack 
of  pain  that  accompanies  their  growth. 

The  methods  of  distinguishing  them  from  tumors  are  various. 
If  they  are  accessible,  the  fluctuation  of  the  fluid  contents  may 
readily  be  perceived.  Sometimes,  when  they  have  existed  for  a 
long  period  without  materially  growing,  a  parchment-like  crackling 
will  be  felt  upon  pressure,  and  it  may  even  be  heard  with  the  ear. 


CYSTS    AND   THEIR   TREATMENT. 


177 


It  sounds  very  much  like  the  crepitating  sound  produced  by  the 

flexing  or  bending  of  bar  tin.     This  is  because  of  the  inspissation, 

or  thickening  into  a  grumous,  clotted  mass  of  the  fluid  contents, 

through  their  desiccation,  or  drying.     In  deeper  cysts  it  is  usually 

advisable  positively  to  determine  their  character  by  aspiration,  or 

the  drawing  off  of  some  of  the  fluid  contents,  by  means  of  an 

aspirating  or  hypodermic  syringe,  and  its  careful  examination. 

This  gives  a  positive  method  of  diagnosis.     An  exploring  needle 

should  also  be  used,  to  determine  the  presence  of  any  foreign  or 

irritating  substance. 

Fig.  47. 


Upper  Jaw  showing  Alveolar  Cyst  and  Other  Diseased  Conditions  the  Result  of 

Neglect. 
There  is  recession  of  the  gums  and  absorption  of  the  alveolar  edges  due  to  pyorrhea. 
The  central  incisor  is  thrown  out  of    alignment  through  the  formation  of  an  alveolar  pocket 
on  the  disto-lingual  aspect.    A  cyst  has  formed  about  the  diseased  apex  of  a  tooth  at  a;  there 
is  chronic  suppuration  with  alveolar  necrosis  at  b.    (From  C.  Rose.) 


Park,  whose  "Surgery  by  American  Authors"  may  be  ac- 
cepted as  the  most  modern  expression  of  surgical  pathological 
knowledge,  divides  these  ordinarily  benign  tumors  into  four 
classes: 

I.  Retention  Cysts.  These  imply  a  previously  existing  cavity, 
zvhose  outlet  is  stopped  up,  and  whose  contents  consequently  accumidate 
and  perhaps  degenerate.  This  class  will  of  course  include  those  oral 
cysts  which  arise  from  an  obstruction  of  the  ducts  of  the  salivary 
gland. 

13 


178 


ORAL    PATHOLOGY   AND   PRACTICE. 


2.  Tubulo-Cysts.  These  are  dilatations  of  certain  fimctionless 
ducts  in  other  parts  of  the  body.  They  are  largely  developmental  in 
their  origin. 

3.  Hydrocele.  This,  as  its  name  indicates,  is  a  collection  of 
watery  fluid  in  some  serous  cavity,  one  which  has  no  discharging  duct 
and  no  opening  of  any  kind.  Hydroceles  are  apt  to  be  of  congenital 
origin,  and  are  most  frequently  found  in  the  region  of  the  neck. 

4.  Glandular  Cysts.  These  growths  are  formed  by  the  dilata- 
tion of  certain  glands.  They  may  usually  be  classed  as  retention 
cysts,  for  the  enlargement  is  most  commonly  induced  by  a  stop- 
page of  the  ducts.  They  may,  however,  occur  in  connection  with 
the  ductless  glands,  and  because  of  this  there  is  a  degree  of  pro- 
priety in  distinguishing  them  from  those  which  arise  from  the  mere 

closing  of  a  duct. 

Fig.  48. 


Calcific,  Structureless  Mass  involving  the  Roots  of  a  Molar. 
It  had  invaded  and  destroyed  cementum  and  dentine.    It  was  as  hard  and  as  dense  as  bone, 
but  had  none  of  its  structure.     (Practice  of  Dr.  A.  M.  Holmes.) 


Those  which  are  of  interest  to  the  oral  surgeon  or  physician 
are  the  first  and  last  classes,  tubulo-cysts  and  hydroceles  not 
being  likely  to  fall  under  his  observation. 

Cysts  in  and  about  the  oral  cavity  are  quite  frequent,  a  con- 
siderable proportion  of  them  being  caused  by  calcareous  deposits 
within  the  salivary  glands  or  in  their  discharging  ducts,  and  the 
subsequent  formation  of  a  retention  cyst. 

Ranula  is  a  retention  cyst,  caused  by  the  stoppage  of  Wharton's 
duct,  or  one  of  the  mucous  glands  beneath  the  tongue.  A  small  cal- 
culus may  be  formed  within  the  gland,  and  it  will  eventually 
become  lodged  somewhere  in  the  duct,  completely  stopping  it.  The 
saliva  or  mucus  is  obstructed  and  forms  a  cystic  pouch  or  pocket, 
into  which  more  is  continually  flowing.     The  watery  portion  will 


CYSTS   AND   THEIR   TREATMENT.  1 79 

be  lost,  and  there  will  remain  a  thick,  jelly-like  mass  beneath  the 
tongue  upon  one  side,  which  in  some  instances  thrusts  that  organ 
quite  out  of  the  mouth.  It  assumes  a  peculiar  mottled  appearance, 
closely  approaching  that  of  a  frog's  belly,  and  hence  it  has  received 
the  name  of  ranula,  from  the  Latin  rana,  a  frog. 

Odontocele  or  Odontoma  is  another  comparatively  common  form  of 
oral  encystment.  These  are  caused  by  the  presence  of  undeveloped 
or  misplaced  tooth  germs.  The  former  term  more  strictly  applies 
to  a  cystic,  and  the  latter  to  a  degenerate  formation,  although  both 
are  due  to  the  same  cause  and  are  of  the  same  general  character. 
They  may  appear  at  any  point  of  the  jaws,  wherever  the  undevel- 
oped germ  may  exist.     They  are  easily  diagnosed  in  most  in- 

FlG.    i\(). 


An  Odontome  Attached  to  a  Molar  Tooth  the  Crown  of  which    is  at 
THE   Apex  of  the  Calcific  Tumor. 

Stances,  not  only  by  the  means  already  laid  down,  but  by  the  addi- 
tional fact  of  there  being  a  missing  tooth,  and  by  their  location 
where  that  might  naturally  be  expected  to  exist.     (See  Fig.  49.) 

Park,  in  his  "Surgery  by  American  Authors,"  says  that  the 
odontomata  are  tumors  composed  of  one  or  more  of  the  dental  tis- 
sues, arising  either  from  tooth  changes  or  teeth  in  process  of  de- 
velopment. He  deprecates  the  lack  of  attention  which  has  been 
given  to  them  in  surgical  literature,  and  says  that  no  tumor  of  the 
jaw,  especially  in  young  people,  should  lead  to  excision  of  the  jaw 
until  it  has  been  fairly  demonstrated  that  it  is  not  one  of  this  form. 

They  are  divided  into — 

I.  Epithelial  Odontomata,  which  are  provided  with  a  cap- 
sule and  present  usually  a  series  of  cysts  separated  by  their  septa, 
containing  a  mucoid  fluid. 


l8o  ORAL    PATHOLOGY   AND    PRACTICE. 

2.  Follicular  Odontomata,  more  frequently  spoken  of  as 
"Dentigerous  Cysts/'  which  arise  in  connection  with  permanent 
teeth,  especially  the  molars,  and  sometimes  reach  a  great  size.  The 
ttimor  consists  of  a  wall  representing  the  expanded  tooth  follicle 
and  a  cavity  containing  viscid  -fluid,  with  parts  of  imperfectly  de- 
ijeloped  teeth,  sometimes  loose  and  in  other  instances  attached. 
They  occur  not  infrequently  in  the  lower  animals. 

3.  Fibrous  Odontomata,  which  consist  of  condensed  connec- 
tive tissue  in  a  developing  follicle  and  present  a  tumor  which  blends 
zvith  the  dental  papilla  at  the  root  and  is  indistinguishable  from  it. 
These  tumors  are  common  in  the  ruminants. 

4.  Cementoma.  This  is  a  tumor  fibrous  in  character  whose 
capsule  has  ossified  or  calcified,  the  developing  tooth  thus  becoming 
imbedded  in  a  mass  of  cementum.  These  occur  freqiiently  in 
horses. 

5.  Compound  Follicular  Odontomata.  These  contain  num- 
bers of  masses  of  cementum  resembling  small  teeth,  or  perhaps 
composed  of  the  three  dental  elements.     (See  Fig.  46.) 

6.  Radicular  Odontomata.  These  are  tumors  of  the  roots 
zvhich  form  after  the  completion  of  the  crown.  They  consist  ex- 
clusively of  dentine  and  cementum,  and  are  rare  in  man. 

7.  Composite  Odontomata.  These  are  hard  tumors,  bearing 
little  or  no  resemblance  in  shape  to  normal  teeth.  They  consist  of 
a  conglomeration  of  enamel,  dentine,  and  cementum,  thus  pre- 
senting an  abnormal  growth  of  all  the  elements  of  the  tooth  germ. 
They  have  been  found  only  in  man. 

There  are  other  forms  of  cysts  arising  from  some  functional 
disturbance  in  the  smaller  glands  of  the  mouth  and  tongue.  They 
belong  to  the  strictly  glandular  class,  and  consist  of  an  enlargement 
or  dilatation  of  a  mucous  gk.nd.  Such  an  one  is  frequently  found 
just  at  the  tip  of  the  tongue,  where  lies  the  so-called  Nuhn's  gland. 
These  cysts,  however,  may  be  of  the  simple  retention  variety,  due  to 
a  stoppage  or  closing  of  the  duct  of  the  mucous  follicle.  Dermoid 
or  congenital  cysts  are  also  sometimes  found  in  the  mouth. 

Sometimes  the  cystic  formation  is  within  the  antrum  of  High- 
more,  which  it  fills  with  cystic  fluid.  In  this  locality  it  is  liable  to  be 
mistaken  for  an  ordinary  edema  of  that  cavity.  But  after  it  has 
existed  for  some  time  it  usually  causes  an  absorption  of  the  walls 
of  the  antrum,  when  its  true  nature  is  revealed.     This  will  most 


CYSTS    AND   THEIR   TREATMENT.  l8l 

often  occur  at  the  external  extremity  of  the  antral  cavity,  where 
the  alveolar  walls  are  thinnest.  At  that  point,  beneath  the  cheek, 
fluctuation  may  readily  be  observed,  and  the  peculiar  feeling  of  the 
cystic  fluid  may  easily  be  detected.  If  there  is  yet  any  doiibt,  an 
aspirator  needle  may  be  introduced,  and  a  little  of  the  fluid  ex- 
tracted. If  this  is  thick  and  glairy,  with  perhaps  some  flocculent 
matter  floating  in  it,  the  diagnosis  will  be  clear. 

There  is  a  kind  of  cyst  that  is  of  a  distinct  interest  to  the  dentist, 
viz,  the  ovarian  dermoid.  These  dermoids  are  teratomatous  growths, 
made  up  of  matter  that  is  developed  from  the  epiblastic  layer. 
Hence  we  find  them  containing  epithelia,  skin,  hair,  sebaceous 
glands,  and  well-developed  teeth.  If  they  should  contain  bone, 
muscle,  or  nerve  tissue  they  would  not  be  dermoids,  because  these 
are  of  mesoblastic  origin.  The  author  has  in  his  possession  a  der- 
moid ovarian  cyst  that  contains  nearly  forty  teeth,  some  of  them 
deciduous  and  some  permanent,  with  hair  rolled  up  into  a  ball  and 
nearly  two  feet  long. 

The  treatment  of  cysts  is  usually  quite  simple.  In  most  cases 
it  is  sufficient  first  to  open  the  cystic  tumor  and  explore  it  for  the 
presence  of  an  irritating  agent.  This,  when  discovered,  should  be 
removed.  The  contents  of  the  cyst  should  now  be  thoroughly 
evacuated,  and  the  cavity  washed  out  with  a  weak  disinfecting 
solution,  when  the  whole  may  be  packed  with  iodized  lint.  Granu- 
lations will  usually  commence  and  complete  the  cure.  It  may  be 
desirable  to  wash  out  the  cavity  with  a  stimulating  fluid,  and  wait 
a  little  time  to  see  that  no  undue  inflammation  succeeds,  before  the 
iodized  lint  is  used. 

In  cysts  within  the  bone,  or  in  the  antrum,  septa  may  exist, 
partially  dividing  the  cavity  into  two  or  more  portions.  These 
should  usually  be  broken  down,  that  the  diagnosis  may  be  complete. 
This  will  be  found  especially  true  in  the  maxillary  sinus. 

In  ranula,  it  is  desirable  to  remove  the  obstructing  calculus 
and  evacuate  the  cyst  without  cutting,  if  it  be  possible,  that  the 
course  of  the  duct  may  not  be  changed.  A  little  careful  manipula- 
tion will  not  infrequently  be  effectual  in  driving  the  concretion,  if 
it  is  not  too  large,  out  through  the  course  of  the  duct,  when  the 
contents  of  the  cyst  may  be  removed  by  means  of  the  aspirator. 
Should  the  cyst  again  fill  up,  it  may  be  necessary  to  open  it,  but  the 
natural  discharge  from  the  submaxillary  gland  should  be  carefull}^ 


1 82  ORAL    PATHOLOGY   AND    PRACTICE. 

provided  for.  There  are  instances  in  which  it  will  be  found  neces- 
sary to  dissect  out  as  much  of  the  inclosing  membrane  as  is 
possible.  There  is  little  danger  from  bleeding  in  any  operation 
upon  cysts,  if  carefully  performed,  and  the  only  complications  are 
those  arising  from  the  ordinary  inflammations. 


CHAPTER  XXXIX. 

TUMORS  AND  NEOPLASMS. 


It  is  not  the  purpose  of  this  work  to  enter  upon  any  extended 
investigation  of  diseases  not  commonly  encountered  by  the  dentist, 
or  which  properly  belong  to  the  practice  of  the  general  physician 
or  that  of  any  other  specialist.  But  it  would  not  be  complete  were 
not  a  sufficient  knowledge  of  morbid  growths  imparted  to  enable 
the  student  intelligently  to  diagnose  the  condition,  even  were  it 
essential  for  him  to  refer  his  patient  to  the  general  surgeon  for  any 
necessary  operation.  Hence,  some  general  remarks  will  be  at- 
tempted concerning  the  origin  and  pathology  of  the  more  common 
foreign  growths. 

The  term  Tumor  implies  an  abnormal  enlargement  of  a  part 
from  any  non-inflammatory  cause,  but  usually  from  a  morbid 
growth,  which  in  its  structure  conforms  to  a  greater  or  less  extent 
to  the  tissue  in  which  it  grows,  and  which  has  no  functional  action. 
A  simple  inflammation  is  a  tumor  in  one  sense,  but  not  in  that 
which  is  surgically  the  accepted  one.  The  term  Neoplasm  is  more 
applicable  to  the  conditions  under  consideration,  because  it  implies 
an  abnormal  growth,  which  may  be  either  normally  or  abnor- 
mally located. 

All  neoplasms,  or  tumors,  consist  of  tissue  that  is  normal  to  the 
body,  and  that  forms  an  essential  part  of  it  when  properly  devel- 
oped. But  when  any  tissue  of  the  body  grows  in  a  location  that  is 
foreign  to  it,  or  when  it  develops  in  an  abnormal  manner  or  in 
excessive  amount,  it  becomes  a  tumor  or  neoplasm.  Every  hyper- 
trophy is  a  tumor,  because  it  is  an  excessive  development,  though 
of  a  normal  tissue  in  a  natural  locality.  If  it  is  developed  in  an  un- 
natural position,  there  is  a  greater  departure.  If  fibrous  tissue 
develops  unconnected  with  other  such  tissue,  or  in  a  place  in  which 


TUMORS   AND   NEOPLASMS.  183 

fibrous  tissue  does  not  belong,  it  is  a  neoplasm.  If  osseous  tissue 
develops  in  undue  amount  in  connection  with  other  bone,  it  may  be 
but  an  hypertrophy  or  a  hyperplasia.  But  if  it  is  formed  in  an  ab- 
normal manner,  or  in  an  unnatural  location,  it  becomes  a  morbid 
tumor.  A  wart  is  the  undue  development  or  an  hypertrophy  of  one 
or  more  of  the  papillae  of  the  skin,  and  it  is  thus  a  form  of  benign 
tumor.  A  corn  is  the  impaction  of  the  epithelia  in  the  tissue  be- 
neath, but  it  is  not  a  true  foreign  growth.  When  epithelia  develop 
unduly  in  the  midst  of  other  tissues,  they  form  a  dangerous  kind  of 
tumor. 

Neoplasms  may  be  of  benign  or  of  malignant  growth.  In  the 
former  case  the  tissue  elements  may  form  a  mere  harmless  hyper- 
trophy, like  hypercementosis,  sometimes  called  exostosis  of  a  tooth, 
while  in  the  latter  they  are  essentially  foreign,  and  therefore  irri- 
tants, and  cause  a  degeneration  and  breaking  down  of  tissue.  All 
neoplasms,  therefore,  are  composed  of  normal  cells  abnormally 
developed  in  number,  as  in  hypertrophies;  in  position,  as  in 
warts,  moles,  etc.;  or  in  both  location  and  histological  arrange- 
ment, as  in  the  malignant  tumors. 

They  are  named  according  to  the  tissue  in  which  they  occur,  or 
of  which  they  are  composed. 

An  Epithelioma  is  composed  of  unduly  developed  epithelia. 

A  Fibroms  is  composed  of  unduly  developed  Uhrous  tissue. 

An  Osteoma  is  composed  of  unduly  developed  osseous  tissue. 

An  Adenoma  is  composed  of  unduly  developed  glandular  tissue. 

An  Enchondroma  is  composed  of  unduly  developed  cartilage  tissue. 

A  Myoma  is  composed  of  unduly  developed  muscular  tissue. 

A  Glioma  is  composed  of  unduly  developed  nerve  structure  tissue. 

An  Angeioma  is  composed  of  unduly  developed  blood  tissues. 

A  Myxoma, of  unduly  developed  mucous  and  gelatinous  tissue. 
Tumors  are  also  named  from  other  peculiarities,  appearances 
and  structural  character,  as — 

Sarcoma;  having  the  appearance  of  flesh. 

Encephaloid;  having  the  appearance  of  a  head. 

Myeloid;  having  the  appearance  of  marrow. 

Melanotic;  having  a  pigmented  or  colored  appearance. 

Scirrhus;  having  a  hard  appearance  or  consistence. 

Medullary;  having  a  soft  appearance  or  structure. 

Tumors  are  also  Homologous  or  Heterologous,  the  former  con- 


184  ORAL    PATHOLOGY    AND    PRACTICE. 

sisting  of  tissue  like,  and  the  latter  unlike,  that  in  which  it  is  im- 
bedded. Homologous  tumors  naturally  are  apt  to  he  benignant,  and 
heterologous  tumors  to  be  malignant  in  their  nature. 

Malignant  tumors  are  usually  connected  with  some  peculiar 
diathesis,  and  there  is  an  hereditary  tendency  toward  their  forma- 
tion. They  are  embryonic  in  structure;  that  is,  made  up  of  not 
fully  developed  tissue,  and  hence  quite  unlike  ordinary  hyper- 
trophies. They  are  apt  to  consist  of  a  network  of  connecting" 
tissues,  whose  meshes  are  filled  with  abnormally  developed  cells. 

They  may  be  diagnosed  from  their  position,  their  history, 
growth,  pain,  general  appearance,  etc.  As  a  rule,  the  faster  the 
growth  the  more  threatening  the  tumor.  This  is  especially  the 
case  if  there  is  pain  attending  it.  Those  which  appear  in  middle 
age  are  more  apt  to  be  malignant  than  those  whose  growth  is 
earlier.  The  most  destructive  ones  are,  after  a  certain  stage,  accom- 
panied with  an  extensive  ulceration  and  sloughing  of  the  tissues. 

A  tumor  will  usually  first  appear  as  a  hard  nodosity  within 
the  tissues.  It  may  increase  in  size  very  fast,  or  its  growth  may 
be  slow.  It  may  be  accompanied  with  considerable  pain,  or  it  may 
be  without  functional  disturbance.  There  are  a  great  many  benign 
tumors  to  each  one  of  a  malignant  character.  As  a  rule,  if  the 
growth  is  slow  and  without  pain,  if  there  is  no  special  reason  for 
its  appearance,  if  it  can  be  attributed  to  no  particular  pathological 
condition  and  no  functional  disturbance  is  connected  with  it,  little 
attention  need  be  paid  to  it.  It  is  probably  one  of  the  frequent 
hyperplasias  of  an  innocent  character  that  may  be  found  in  almost 
every  person.  It  is  usually  safe  under  all  circumstances  to  allay 
the  fears  which  such  an  appearance  almost  invariably  excites,  by 
the  assurance  that  it  is  one  of  the  numerous  growths  that  can  do 
no  harm,  and  to  endeavor  to  divert  the  mind  from  all  thoughts  of  it. 
Nothing  should  ever  be  said  that  can  excite  apprehension.  Even  if 
the  practitioner  is  in  doubt  concerning  its  true  nature,  he  should 
not  let  the  patient  become  aware  of  it.  He  should  keep  it  under 
observation  until  it  has  sufficiently  developed  to  enable  him  to  judge 
intelligently,  but  always  without  communicating  alarm. 

The  treatment  of  the  homologous  tumors  is  wlioUy  local.  They 
have  no  constitutional  origin,  and  do  not  menace  life.  The  chief 
reason  for  interfering  at  all  in  many  such  cases  will  be  found  in  the 
fact  of  their  causing  inconvenience  or  disfigurement. 


TUMORS    AND    NEOPLASMS.  155 

The  heterologous  tumors  represent  a  constitutional  vice.  They 
tend  to  infiltrate  into  and  invade  other  tissues.  Especially  are  they 
likely  to  affect  the  glandular  system.  Local  treatment  is  entirely 
useless,  and  even  if  they  are  removed  they  are  quite  likely  to  re- 
appear. They  never,  like  the  homologous  tumors,  reach  a  definite 
limit  of  growth,  but  continue  to  increase  and  spread.  Their  treat- 
ment, aside  from  surgical  interference,  which  is  usually  advisable 
except  in  the  later  stages,  must  be  specific  and  sustaining. 


CHAPTER  XL. 

TUMORS  AND  NEOPLASMS  (Continued). 

The  term  Cancer  is  one  that  is  not  usually  employed  by  pro- 
fessional men.  It  is  derived  from  the  Latin  cancer,  a  crab,  and 
the  name  is  given  from  the  supposed  crab-like  appearance  of  the 
veins  in  this  afifection.  The  laity  usually  understand  by  it  any  of 
the  malignant  growths  which  are  technically  called  Sarcoma  or 
Carcinoma  or  Epithelioma.  Of  these  the  sarcomata  are  composed 
of  embryonic  tissue  from  the  mesoblastic  layer,  while  the  carci- 
nomata  are  of  epiblastic  origin.  Each  is  variously  subdivided 
according  to  its  character  or  development,  and  each  presents  sepa- 
rate physical  and  pathological  characteristics. 

Sarcomas  have  a  distinct  kind  of  fleshy  appearance,  and  seem  to 
be  specially  vascular.  They  grow  along  the  lines  of  least  resistance,, 
and  are  likely  to  penetrate  into  cavities  and  fissures  of  the  tissues. 
They  appear  at  any  age,  and  are  comparatively  rapid  in  their 
growth,  sometimes  causing  considerable  pain.  When  they  appear 
upon  the  surface  they  bleed  very  easily,  and  have  in  such  cases 
sometimes  been  known  as  Fungous  Hematodes.  They  are  com- 
paratively frequent  in  the  salivary  glands,  in  the  jaws  and  other 
tissues  of  the  mouth,  sometimes  penetrating  to  the  antrum.  They 
are  quite  common  in  some  of  the  lower  animals,  especially  the 
horse. 

An  Osteo-sarcoma  is  one  in  which  the  bone  tissue  is  in- 
volved. It  may  be  Central,  arising  in  the  interior  and  distending 
the  bony  walls;  Infiltrating,  when  the  whole  bony  mass  is  perme- 


i86 


ORAL   PATHOLOGY   AND    PRACTICE. 


ated  and  softened,  or  Periosteal,  when  it  has  its  origin  in  the 
periosteum.     (See  Fig.  50.) 

Carcinoma  is  of  epihlastic  origin,  and  is  connected  with  some 
form  of  gland  tissue.  It  is  rare  in  young  persons,  and  it  commonly 
involves  the  lymphatics  at  an  early  period  of  its  development.  It 
is  usually  rapid  in  its  growth,  and  it  may  cause  a  very  great  degree 
of  pain.  It  is  very  apt  to  attack  the  breast  in  women,  but  its  seat 
m.ay  be  in  the  sebaceous  glands,  the  salivary  glands,  the  prostate. 


Fig.  50. 


Osteo-Sarcoma  of  the  Lower  Jaw.     (From  a  specimen  in  the  Buffalo  College  Museum.) 

liver,  kidney,  testicles,  stomach,  intestines,  especially  the  rectum,  or 
wherever  glandular  tissue  exists.  Hence  its  location  will  be  an 
important  guide  in  its  diagnosis. 

Epithelioma,  as  its  name  indicates, is  a  degeneration  of  an  epithelial 
surface,  ttsually  of  the  skin,  and  consists  of  masses  of  epithelial  cells 
siirrounded  and  separated  by  hands  of  connective  tissue.  It  belongs 
to  the  malignant  growths,  though  it  does  not  necessarily  assume 
their  form.  It  is  most  apt  to  attack  those  beyond  middle  life,  and 
is  much  more   common  in   men  than   in   women.     It   sometimes 


TUMORS    AND    NEOPLASMS.  iS/ 

arises  upon  the  lip,  from  the  long-continued  irritation  of  a  pipe.  It 
is  also  not  infrequently  caused  upon  the  tongue,  or  in  the  oral  tis- 
sues, by  the  pressure  of  rough,  sharp  edges  in  carious  teeth,  which 
act  as  a  continuous  provocation.  Its  diagnosis  is  not  usually  diffi- 
cult. Its  late  and  superficial  appearance  and  the  chronic  ulcer 
with  indurated  edges  forbid  its  being  readily  confounded  with  any- 
thing else,  unless  it  might  be  some  forms  of  syphilis. 

Lupus  is  one  of  the  many  forms  ivhich  tiiherculosis  assumes. 
It  is  strictly  a  communicable  disease,  and  is  due  to  an  infection  by 
the  tubercle  bacillus.  It  usually  commences  early  in  life  upon  the 
face,  in  the  form  of  small  red  or  dark  spots,  which  are  much  softer 
than  the  inclosing  tissue.  They  ulcerate  in  time,  and,  spreading 
with  the  deposition  of  more  tuberculous  matter,  there  is  a  steady 
erosion  into  the  surrounding  territory.  The  infection  of  the  system 
with  the  tubercle  bacillus  is  always  a  grave  matter,  and  is  liable  to 
cause  many  complications.  It  is  a  question  to  be  taken  into  careful 
consideration  when  any  surgical  measures  are  contemplated,  be- 
cause the  appearance  of  miliary  tubercle  would  interfere  with  the 
healing  process.  It  is  impossible  within  the  limits  of  a  work  like 
this  thoroughly  to  consider  the  many  phases  which  tuberculosis 
may  assume,  and  the  student  who  desires  further  information  is 
referred  to  works  upon  general  surgery. 

Of  the  non-malignant  tumors,  those  most  commonly  found  in 
the  mouth  are  the  different,  forms  of  fibroma.  These,  as  their  name 
indicates,  are  composed  of  fibrous  tissue.  They  are  ordinarily 
dense  in  structure,  and  composed  of  bundles  closely  packed  to- 
gether, which  are  permeated  by  bloodvessels.  The  Epulids  belong 
to  this  class,  as  they  are  of  fibrous  origin. 

Lipomas,  or  fatty  tumors,  are  the  most  frequent  of  any  of  the 
neoplasms.  They  are  of  the  adipose  tissue  type,  and  it  is  needless 
to  say  are  harmless  in  their  character.  They  are  usually  inclosed 
in  a  capsule,  from  which,  if  no  vital  organ  is  involved  in  these  folds, 
they  may  readily  be  enucleated.  They  are  easy  of  recognition, 
except  when  deeply  located,  and  when  once  extirpated  are  not  apt 
to  return. 

The  Osteomas  are  bony  tumors,  and  are  by  some  believed  to  be 
chondromas,  or  cartilaginous  tumors,  which  have  ossified.  They 
may  be  either  compact  or  cancellous  in  structure.  They  are  most 
common  about  the  cranium,  and  may  be  found  in  the  frontal  sinus, 


I50  ORAL    PATHOLOGY    AND    PRACTICE. 

the  external  auditory  meatus,  and  about  the  mastoid  process.  The 
compact  forms  are  sometimes  very  dense  and  hard,  appearing  like 
ivory,  and  they  may  defy  the  finest  steel  instruments.  Some  forms 
of  odontoma  are  classed  with  osteomas. 

The  student  will  be  especially  interested  in  the  methods  by 
which  tumors  of  malignant  growth  may  be  distinguished  from 
those  which  are  benign.  This  may  usually  be  done  by  the  clinical 
symptoms,  although  there  are  instances  in  which  the  most  careful 
observation  will  be  at  fault.  Some  of  the  foreign  growths  will  pre- 
sent misleading  characteristics,  but  the  following  points  of  differ- 
ence may  usually  be  relied  upon: 

Benign  tumors  are  common  to  all  ages,  while  those  which  are 
malignant  do  not  appear  in  early  life. 

Benign  tumors  are  slow  in  formation,  while  the  malignant  are 
usually  of  rapid  growth. 

Benign  tumors  do  not  spread  and  infiltrate  into  the  surrounding 
tissues,  while  those  which  are  malignant  infiltrate  in  all  cases. 

Benign  tumors  are  often  inclosed  in  a  capsule  and  are  circum- 
scribed, while  malignant  tumors  are  never  thus  limited. 

Benign  tumors  are  rarely  adherent,  while  malignant  ones  al- 
ways are. 

Benign  tumors  rarely  ulcerate,  while  the  malignant  ones  al- 
ways do  when  they  come  to  the  surface. 

In  benign  tumors  the  overlying  tissue  is  not  disturbed,  while 
in  the  malignant  it  is  more  or  less  retracted. 

There  is  no  lymphatic  involvement  in  the  benign  tumors  unless 
they  are  inflamed,  while  malignant  tumors  almost  always  involve 
the  lymphatics. 

The  treatment  of  the  tumors  is  almost  exclusively  surgical. 
Those  which  are  benign  seldom  return  when  they  have  been  ex- 
tirpated, while  the  malignant  ones  usually  do.  If  the  latter  have 
made  considerable  progress,  and  especially  if  the  lymphatic  glands 
have  become  enlarged  and  indurated,  they  are  almost  certain  to 
reappear.  Yet  excision,  even  of  the  most  destructive  forms,  will 
usually  prolong  life,  if  it  does  not  permanently  save  it.  There  is 
but  one  safe  method  of  removing  them,  and  that  is  by  the  knife. 
The  eroding  plasters  of  the  so-called  "cancer  doctors"  are  not  only 
the  most  painful  means  of  effecting  removal,  but  are  eminently 
dangerous,  being  very  apt  to  hasten  infiltration,  and  in  some  in- 


TUMORS    AND    NEOPLASMS.  189 

stances  they  may  convert  a  tumor  of  a  benign  aspect  into  a  malig- 
nant type. 

The  dentist  will  be  mainly  interested  in  the  epulitic  growths 
that  are  common  in  the  mouth.  The  usual  form  of  epulis  is  a  vas- 
cular tumor  that  appears  upon  the  gums.  Its  origin  may  be  from 
the  superficial  fibers,  from  the  pericementum  of  a  tooth,  or  it  may 
penetrate  into  and  appear  to  have  its  root  in  the  alveolus.  The 
term  "Epulis"  means  "upon  the  gums."  Hence  it  is  applicable  to 
any  abnormal  gingival  growth,  and  the  hypertrophies  that,  proceed- 
ing from  the  gums,  sometimes  fill  the  cavities  in  decayed  teeth  are 
true  epulids,  though  of  a  simple  character.  Epulids  may  appear 
as  erectile  or  as  non-erectile  tissue,  and  may  have  fibrous,  myeloid, 
myxomatous  or  sarcomatous  complications. 

The  erectile  epulids  are  vascular  grozvths,  whose  size  depends 
upon  the  vascular  condition,  and  they  vary  with  this.  When  dis- 
tended they  appear  tinged  and  dark.  When  not  distended  they  are 
Uaccid,  pale,  and  contracted. 

The  epulitic  tumors  that  spring  from  the  periosteum  perhaps 
invade  the  substance  of  the  bone.  They  may  be  diagnosed  by 
careful  movements  and  by  the  exploring  needle,  which  may  pos- 
sibly detect  an  opening  into  the  bone. 

If  the  origin  is  from  the  pericementum  of  a  tooth,  a  peduncular 
connection  may  usually  be  traced,  either  through  the  alveolar  walls 
or  by  the  side  of  the  tooth,  in  the  direction  of  the  pericemental 
membrane. 

For  the  removal  of  the  superficial  and  erectile  tumors,  little 
more  is  needed  than  a  ligature  that  shall  cut  off  all  circulation,  with 
final  cauterization  of  the  place.  An  epulis  that  has  its  origin  in  the 
pericementum  of  a  tooth  will  be  cured  by  extraction.  But  for 
those  which  penetrate  the  bone,  it  will  be  necessary  to  remove  as 
much  of  the  alveolus,  or  even  the  body  of  the  maxilla,  as  is  afifected, 
remembering  that  the  extremity  of  the  invasion  must  be  reached. 
The  wound  should  be  dressed  with  iodized  lint.  If  there  is  much 
inflammation  the  following  may  be  applied : 

? — Plumbi  acetatis,  3ij ; 

Tinct.  opii,  §ij ; 

Aquae,  Bxvj. 

Sig. — Pack  the  wound  with  lint  wet  with  the  solution. 


IQO  ORAL    PATHOLOGY    AND    PRACTICE. 

CHAPTER  XLI. 

OSTEITIS. 

Before  entering  upon  the  consideration  of  diseases  of  the 
bone  it  is  necessary  thoroughly  to  comprehend  the  pathological 
changes  involved  in  the  initial  steps  of  the  degeneration.  Bone, 
which  forms  the  framework  of  the  body,  is  made  up  of  an  inorganic, 
or  mineral  portion,  and  an  organic,  or  living  part.  The  latter  is  con- 
tained within  the  meshes  of  the  former,  and  communicates  through 
the  whole  structure  of  the  bone.  This  is  accomplished  by  means 
of  the  peculiar  formation  of  the  inorganic  part.  It  is  through  the 
organic  or  living  portion  that  nutriment  of  the  whole  osseous 
tissue,  is  carried  on.  The  changes  that  occur  in  the  inorganic 
portion,  the  waste  and  repair,  are  not,  of  course,  as  great  as  those 
of  vascular  tissue,  yet  they  must  be  provided  for  in  the  economy  of 
nature. 

The  nourishment  of  the  bone,  like  that  of  all  other  tissues,  must 
primarily  be  derived  from  the  blood,  and  it  is  carried  on  through  the 
periosteum  or  investing  membrane,  the  medullary  marrow  or  central 
cavity  in  long  bones,  and  the  Haversian  or  penetrating  canals  which 
carry  the  blood  to  all  portions  of  the  thick  bones.  Around  the 
Haversian  canals,  and  along  all  the  sources  of  nutriment,  are 
arranged  a  concentric  series  of  cells  containing  the  essential  living 
matter  of  the  bone.  (See  Fig.  51.)  These  cells  are  the  lacunae, 
and  each  of  the  zones  of  these  so  concentrically  arranged  cells  is 
called  a  lamella.  Connecting  the  several  lacunae,  and  communicat- 
ing with  the  nutrient  source — the  periosteum,  the  medulla,  or  the 
Haversian  canals — are  the  canaliculi,  the  minute  canals  which  carry 
the  pabulum  extracted  from  the  blood  to  the  lacunas,  the  immediate 
source  of  nutriment. 

The  living  contents  of  the  lacunae  and  the  communicating 
canaliculi  are  of  a  protoplasmic  or  embryonal  character,  and  contain 
the  elements  of  the  osseous  tissue.  If  the  nutrition  of  its  structure 
is  cut  off,  the  bone  dies  as  inevitably  as  does  any  other  tissue  under 
like  circumstances.  If  a  ligature  is  placed  about  the  finger  that 
is  sufficient  to  prevent  all  circulation,  and  thus  to  stop  all  nutriment, 
the  soft  tissue  will  die  and  become  gangrenous.     If  the  ligation  is 


OSTEITIS. 


191 


SO  complete  as  to  deprive  the  bone  of  its  nutrient  currents,  that  will 
also  die  from  the  same  reason,  and  become  necrosed. 

If  the  stoppage  of  nutrition  in  the  finger  is  through  a  progres- 
sion of  the  inflammatory  process,  by  hyperemia,  congestion,  and 
final  stasis  of  the  blood  current  in  the  part,  the  result  is  precisely 
the  same  as  if  it  were  through  a  ligature,  or  separation  of  all  arterial 
sources  of  supply.  It  matters  not  by  what  the  nutrition  is  com- 
pletely interrupted,  whether  by  starvation — stoppage  of  food  supply 
either  to  a  part  or  the  whole  of  the  body  by  cutting  off  that  supply 


Fig.  si. 


Lamella  of  Bone,  showing  also  the  Lacunae  and  Canaliculi.     (From   Gray.) 

through  interruption  of  the  channel  of  conveyance — or  by  such 
pathological  changes  as  completely  to  prohibit  assimilation  of  food 
products,  death  of  a  part  or  the  whole  of  whatever  is  thus  deprived 
of  its  food  supply  must  be  the  inevitable  result.  In  the  soft  tissues 
this  may  be  called  suppuration,  ulceration,  sloughing,  or  gangrene, 
and  in  the  hard  portions  caries,  exfoliation,  or  necrosis,  but  it  is 
essentially  all  the  same  process.  Each  is  but  a  different  manifesta- 
tion of  the  universal  law  of  death  and  decay  whenever  nutrition  and 
progress  cease.  The  instant  that  progression  stops,  retrogression 
commences. 

The  contents  of  the  lacunae  and  canaliculi  of  bone,  the  proto- 
plasmic embryonic  elements,  although  they  are  not  directly  vas- 


192  ORAL    PATHOLOGY   AND    PRACTICE. 

cular,  may  be  the  subjects  of  inflammatory  action.  This  process, 
differing  from  ordinary  inflammation  in  some  particulars  because 
of  the  varying  physical  character  of  the  affected  substance  itself, 
as  well  as  of  its  environments,  will  arise  from  the  same  causes  as 
do  inflammations  of  other  tissues,  and  may  be  studied  from  the 
same  standpoint. 

The  initial  point  will  undoubtedly  be  in  the  tissue  or  organ 
that  is  the  immediate  source  of  food  supply, — the  periosteum,  the 
investing  or  lining  membrane  of  the  bone.  Disorders  of  this  tissue 
must  affect  the  living  portion  of  the  bone.  Inflammation  of  the 
periosteum,  if  the  degenerative  process  continues,  ends  in  stasis  of 
the  blood  currents,  thus  cutting  off  nutrition,  with  the  consequent 
deterioration  of  the  living  contents  of  the  lacunae  and  canaliculi. 

This  inflammation,  or  affection  of  the  living  portion  of  the  hone,  is 
-that  which  we  call  osteitis,  and  it  is  iisually  the  initial  point  of  necrosed 
conditions.  If  the  osteitis  is  relieved  through  the  removal  of  the 
source  of  irritation  and  the  re-establishment  of  nutrient  currents, 
that  is  essentially  the  resolution  spoken  of  in  dealing  with  Inflam- 
mations. If  it  proceeds  to  the  breaking  down  of  tissue  it  will  be 
caries  or  necrosis,  the  analogues  respectively  of  suppuration  and 
gangrene. 

Like  all  other  inflammatory  conditions,  osteitis  is  the  result  of 
some  irritant.  This  may  be  a  traumatic  lesion,  the  presence  of 
pus  or  of  a  foreign  body,  or  the  interference  with  nutrition  caused 
by  some  external  impression  manifested  through  the  nervous  sys- 
tem. Anything  that  would  induce  the  inflammatory  process  in  the 
soft  tissues  may  in  a  less  degree  be  provocative  of  osteitis  in  the 
hard.  Probably  there  was  never  an  acute  pericementitis  that  did 
not  induce  a  corresponding  osteitis  in  the  bony  tissues  in  the  imme- 
diate proximity.  We  know  that  an  alveolar  abscess  causes  a 
breaking  down  of  the  bone  abo'Ut  the  infected  spot,  and  the  forma- 
tion of  a  cavity  of  greater  or  less  extent.  We  are  also  but  too  well 
aware  that  pus  from  an  abscess  sometimes  infiltrates  the  bone,  and 
will  burrow  to  a  considerable  distance,  forming  secondary  pockets 
and  foci  of  infection,  which  sometimes  make  thorough  sterilization 
very  difficult.  We  know,  too,  that  it  takes  considerable  time  to 
effect  the  complete  healing  of  the  pockets  and  cavities  in  the  bone 
thus  formed,  and  that  until  the  embryonic  or  temporary  tissue  that 
is  the  result  of  the  first  reparative  process  shall  have  time  to  con- 


OSTEITIS.  193 

solidate  and  become  permanent  through  further  progressive 
changes,  there  is  always  danger  that  the  metamorphosis  will  take 
upon  itself  a  retrogressive  state  and  the  whole  again  break  down. 
All  these  conditions  go  to  demonstrate  the  fact  that  osteitis,  to  a 
greater  or  less  degree,  is  always  present  in  pericemental  complica- 
tions, and  that  in  the  treatment  of  such  conditions  its  existence 
should  be  taken  into  account  and  care  taken  that  it  be  kept  in 

check. 

Symptoaiatology  and  Treatment. 

The  diagnosis  of  osteitis  as  a  separate  infection  is  not  readily 
made,  and  principally  depends  upon  other  known  degenerative 
processes.  The  existence  of  an  abscess  in  the  immediate  neighbor- 
hood of  any  osseous  tissue  must  inevitably  induce  it.  The  mere 
presence  of  pus  and  of  the  micro-organisms  of  suppuration  are 
sufficiently  irritating  to  provoke  an  inflammation  of  periosteum, 
and  that  necessarily  implies  more  or  less  of  osteitis.  But  aside 
from  such  recognizable  complications  the  condition  does  not  pre- 
sent sufficient  of  pathognomonic  symptoms  to  enable  the  observer 
always  to  detect  it  in  its  earlier  stages.  It  may  often  be  inferred, 
and  in  some  instances  perhaps  determined,  by  exclusion  of  all  other 
functional  disturbances,  but  the  pathologist  must  mainly  depend 
upon  associated  disorders  for  his  complete  diagnosis. 

The  periosteal  inflammation  that  is  the  cause  of,  or  that 
accompanies  it,  will  manifest  itself  by  a  red  line,  or  red  blotches 
upon  the  superincumbent  tissues,  provided  they  are  not  too  thick, 
and  this  will  be  intensified  if  there  is  very  much  of  osteitis  present. 
But  this  cannot  be  depended  upon  as  a  certain  diagnostic  symptom, 
though  it  may  be  useful  as  an  adjunct. 

The  treatment  of  osteitis  in  its  early  stages  should  be  abortive, 
and  it  will  not  materially  differ  from  that  laid  down  for  the  relief 
of  inflammation  in  other  tissues  in  the  chapter  (X.)  devoted  to 
that  subject.  Its  presence  once  determined,  every  effort  shovild  be 
made  to  discover  the  source  of  irritation  and  to  remove  it.  About 
the  jaws  this  will  most  frequently  be  a  diseased  tooth,  and  when 
that  is  restored  to  a  healthy  state,  unless  the  disorder  shall  have 
existed  for  some  time  or  the  lesions  be  unusually  violent,  the 
inflammation  in  the  lacunae  of  the  bone  will  subside  with  the  rest. 
If,  however,  this  is  not  the  case,  and  the  retrogression  or  degenera- 
tive action  persists,  it  will  result  in  either  caries  or  necrosis  of  the 
bone,  and  these  will  be  considered  under  their  a]:)propriate  heads. 

14 


194  ORAL    PATHOLOGY    AND    PRACTICE. 

CHAPTER    XLIL 

CARIES  OF  ALVEOLAR  BONE. 

In  dental  practice  this  disease  may  be  compared  to  suppuration 
or  ulceration  in  soft  tissues.  It  is  the  devitalization  of  bone,  cell 
by  cell,  and  its  breaking  down  by  a  comparatively  slow  progression, 
rather  than  death  in  mass.  It  has  its  origin  in  perverted  or  inter- 
rupted nutrition,  but  the  phenomena  exhibited  vary  somewhat  from 
those  of  necrosis.  It  most  frequently  arises  from  local  irritations, 
but  it  may  be  general  and  constitutional  in  its  origin,  as  in  the  case 
of  scrofulous  subjects  or  those  affected  by  the  syphilitic  virus.  A 
frequent  source  of  maxillary  caries  will  be  found  in  the  diseased 
roots  of  teeth,  which  act  as  sources  of  irritation.     Not  infrequently, 


Loss  OF  Septa  through  Alveolar  Caries. 
a,  Depressions  in  the  bone,  with  denudation  of  the  cervix  of  the  tooth. 

too,  it  is  the  result  of  excessive  violence  in  dental  operations. 
Long-continued  wedging  will  be  likely  to  induce  a  local  osteitis  so 
severe  as  to  interfere  with  the  nutrition  of  the  thin  septa  of  bone 
between  the  teeth,  denude  them  of  periosteum,  and  result  in  a 
wasting  caries  which  will  destroy  that  portion  of  the  alveolar 
process  by  slow  disintegration.      (See  Fig.  52.) 

It  will  be  comprehended  that  this  form  of  caries  materially 
differs  from  that  which  is  by  surgeons  usually  denominated  caries 
of  the  bone,  both  in  its  etiology  and  symptomatology.  While  it 
may  be  aggravated,  or  even  induced,  by  cachectic  conditions,  it  is 
not  characterized  by  the  substituted  granulation  tissue.  It  more 
resembles  in  its  progression  dental  caries,  but  is  quite  distinct  from 
the  latter  in  many  of  its  characteristics.     This  form  of  caries  of  the 


CARIES  OF  ALVEOLAR  BONE.  I95 

bone  may  be  readily  diagnosed,  through  careful  examinations,  by 
any  one  who  is  skilled  in  such  matters  or  who  has  cultivated  habits 
of  close  observation.  Yet  the  earlier  periods  in  these  perversions 
are  recognized  by  but  few  dentists,  because  their  perceptions  have 
not  been  sharpened  by  continual  practice.  Either  they  are  not 
sufficiently  instructed  to  know  what  to  look  for,  or  they  do  not 
extend  their  observations  beyond  the  teeth  themselves,  and  neglect 
everything  save  that  which  obviously  demands  mere  mechanical  or 
operative  interference.  Any  localized  congestion  or  inflammatory 
turgescence  and  swelling  demands  the  attention  of  the  practitioner. 
It  may  be  indicative  of  a  slight  disturbance,  or  it  may  be  the  initial 
point  of  a  serious  lesion.  The  oral  physician  should  be  competent 
to  determine  which  it  is,  and  faithful  enough  to  keep  it  under 
observation  until  it  shall  develop  its  true  character;  and  the  condi- 
tion should  be  recognized  early  enough  to  enable  the  practitioner 
to  obviate  the  spontaneous  formation  of  sinuses. 

True  caries  of  bone  will  produce  a  marked  change  in  the  over- 
lying soft  tissues.  There  will  in  the  incipiency  be  great  determina- 
tion of  blood  to  the  parts,  with  congestion  and  tumidity.  This  will 
gradually  assume  a  deeper  color,  until  it  approaches  a  purple  hue 
and  sloughing  commences. 

In  simple  denudation  caries  of  the  maxillary  process  there  will 
be  very  little  of  this,  nor  will  there  be  any  very  considerable  forma- 
tion of  pus.  But  there  will  be  limited  sloughing  of  the  superim- 
posed tissues,  with  denudation  of  the  bone,  more  or  less  complete, 
beneath.  An  opening  through  the  soft  tissues  will  be  found,  and 
this  may  be  discharging  a  small  amount  of  pus,  though  without 
acute  complications.  If  now  a  probe — the  best  one  for  such  cases 
is  a  hatchet-shaped  excavator — or  an  explorer  of  some  kind  be  car- 
ried through  this  opening,  the  bone  will  be  found  quite  denuded  and 
exposed.  The  point  of  the  excavator  will  readily  enter  it,  and 
small  spicula  from  the  roughened  surface  may  be  readily  chipped 
off.  There  will  be  none  of  the  smooth,  solid,  resisting  sensation 
that  a  healthy  bone  presents.  To  the  educated  sense  of  touch  it 
presents  characteristics  that  cannot  well  be  mistaken.  If  there  is 
caries  of  the  septum  of  the  bone  between  the  teeth,  the  result  of 
traumatic  violence,  perhaps  in  wedging  or  filling,  there  will  be  a 
peculiarly  rough,  gritty  feeling,  showing  that  portions  of  it  have 
been  thrown  off,  with  destruction  of  the  periosteum.     There  may  be 


196  ORAL    PATHOLOGY    AND    PRACTICE. 

a  distinct  putrefactive  odor  from  the  diseased  territory,  showing 
that  food  is  undergoing  decomposition  there,  even  if  there  is  no 
appreciable  formation  of  pus.  These  conditions  and  appear- 
ances distinguish  alveolar  caries  from  the  resorptions  of  the 
alveoli  which  normally  occur  after  the  extraction  of  the  teeth  and 
the  destruction  of  the  pericementum,  upon  the  integrity  of  which 
membrane  the  tooth  sockets  are  dependent. 

The  treatment  of  this  form  of  caries  of  the  bone  will  be  almost 
entirely  local.  If  the  degeneration  is  extensive,  it  may  possibly' 
indicate  a  general  debility  that  will  demand  the  use  of  tonics,  but 
this  will  be  very  unusual,  to  say  the  least.  The  dead  and  carious 
bone  should  be  burred  away  with  the  dental  engine,  and,  if  neces- 
sary, the  diseased  surface  carefully  curetted  or  scraped.  This 
process  must  be  carried  to  the  extreme  limits  of  the  affected  bone, 
which,  unless  there  is  a  carious  sinus,  will  not  be  very  deep. 

This  done,  and  all  debris  carefully  washed  away,  the  surface  of 
the  diseased  bone  may  be  saturated  with  aromatic  sulphuric  acid, 
which  may  be  allowed  to  act  for  a  few  minutes,  when  the  cavity 
should  be  thoroughly  washed  with  water.  That  an  acid,  especially 
sulphuric,  will  exercise  a  selective  action,  dissolving  only  dead  tis- 
sue, seems  to  be  proved  by  the  experiments  of  the  late  Prof.  J.  E. 
Garretson,  who  caused  to  be  submitted  to  the  action  of  a  twenty- 
five  per  cent,  solution  of  sulphuric  acid,  for  three  days,  fragments  of 
dead,  of  diseased,,  and  of  healthy  bone,  with  the  result  that  in  dead 
bone  a  considerable  proportion  of  the  lime  salts  was  dissolved,  in 
the  diseased  bone  a  less  amount,  while  in  the  healthy  bone  no  such 
action  took  place.  Great  care  must  subsequently  be  exercised  to 
keep  the  territory  clean  and  aseptic,  disinfectants  or  antiseptics 
being  used  if  necessary. 

If  the  tissues  seem  indolent,  they  may  be  stimulated  to  action 
by  the  use  of  a  weak  solution  of  the  chloride  or  iodide  of  zinc. 
Opportunity  must  be  given  for  the  formation  of  a  new  periosteum, 
and  when  the  reparative  process  is  once  under  way  the  forming* 
tissue  must  be  left  undisturbed,  except  for  occasional  gentle  irriga- 
tions with  an  antiseptic  or  stimulative  solution  when  that  is  abso- 
lutely necessary.  Many  practitioners  defeat  their  own  efforts  by 
uncalled  for  and  meddlesome  interference — by  over-treatment  when 
all  is  progressing  satisfactorily. 

The  preceding  remarks  apply  more  directly  to  caries  of  the 


CARIES    OF    ALVEOLAR    RONE.  19/ 

alveolar  process  of  the  jaws.  In  caries  of  other  bones  there  is 
almost  always  some  cachectic  condition,  such  as  tuberculosis  or 
syphilis,  which  induces  the  carious  degenerations.  (See  Fig.  53.) 
If  there  is  infection  by  septic  organisms  suppuration  of  course 
ensues,  and  the  disease  may  assume  a  more  destructively  active 
necrotic  type.  In  dry  caries  of  the  alveolar  process,  which  is  the 
form  most  frequently  met  with  by  the  oral  practitioner,  there  is 
nothing  of  this  kind,  nor  is  there  necessarily  a  constitutional  dys- 
crasia,  the  local  irritation  being  sufificient  to  induce  the  gradual 
wasting  of  the  cancellous  bony  tissue,  through  the  gradually  pro- 
gressive cutting  off  of  nutrition. 

Fig.  53- 


Caries  of  Ulna  and  Radius. 
There  are  no  such  cavities  found  in  the  bone  as  in  Fig.  5^. 

In  oral  practice,  then,  a  distinction  may  readily  be  made  be- 
tween the  carious  disintegrations  of  the  alveolar  process  of  the 
jaws  that  may  not  be  accompanied  by  any  specially  inflamed  con- 
ditions and  in  which  there  are  few  if  any  traces  of  ulceration, 
and  the  porous,  abscessed  state  of  true  caries,  which  is  surrounded 
by  foreign,  unhealthy  granulations  of  the  soft  tissues.  The  one  is 
merely  a  gradual  disintegration  of  the  alveoli,  brought  about  by  the 
deprivation  of  the  nutrient  supply,  with  denudation  of  the  process 
by  sloughing  of  the  periosteum.  The  other  is  the  breaking  down 
01  osseous  tissue  with  the  formation  of  fetid  pus,  which  tends  to 
burrow  into  the  tissue.  The  first  is  due  to  simple  lack  of  nutrition, 
usually  the  result  of  some  injury,  while  the  other  is  a  cachectic 
state  arising  from  some  constitutional  disturbance,  the  tuberculous 
deposit  being  its  most  frequent  accompaniment. 

The  only  treatment  demanded  by  the  progressive,  crumbling 
of  the  alveolar  process  will  be  to  remove  any  irritating  cause,  bur 
out  the  bone  that  is  denuded  of  its  periosteal  covering  and  that  is 


198  ORAL    PATHOLOGY   AND    PRACTICE. 

disintegrating,  retain  the  gum  tissue  in  place  over  it — by  stitches 
if  necessary — and  then,  by  the  use  of  stimulating  astringents,  to 
induce  a  new  membranous  growth. 

If  there  is  an  ulcerative  condition,  due  to  a  dyscrasia,  constitu- 
tional treatment  will  be  demanded,  and  this  will  consist  in  the  pre- 
scribing of  nutritious  diet,  cod-liver  oil,  hypophosphites,  syrup 
of  iodide  of  iron,  etc.,  with  the  local  treatment  previously  recom- 
mended, and  specific  remedies  when  indicated. 


CHAPTER  XLIII. 
NECROSIS. 


Necrosis  of  the  hard  tissue  is  the  analogue  of  gangrene  in  the 
soft.  Its  progress  is  not  so  rapid,  because  of  the  difference 
in  the  physical  characteristics  of  the  tissues  themselves.  But  its 
origin  is  in  an  identical  disturbance  of  nutrition,  its  course  presents 
the  same  pathological  changes,  the  termination  is  usually  similar, 
and  the  treatment  involves  the  consideration  of  cognate  principles. 
Inflammation  forms  the  initial  point  in  its  morbidity,  and  it  is  from 
that  standpoint  that  the  degenerate  modifications  should  be 
studied. 

Necrosis  differs  from  caries  of  the  bone  rather  in  degree  than  in 
essence.  As  gangrene  is  the  death  of  soft  tissues  in  mass,  so 
necrosis  is  the  devitalization  of  a  territory  having  an  osteogenetic 
origin.  Like  caries  of  bone,  its  cause  may  be  either  traumatic  or 
specific,  local  or  constitutional.  It  may  attack  any  of  the  bones, 
but  the  maxillae  are  especially  subject  to  it ;  necrosis  of  the  lower 
jaw  is  four  times  as  common  as  in  the  upper.  In  simple  caries  of 
the  alveoli  this  proportion  is  nearly  reversed.  When  not  the  result 
of  an  injury,  its  origin  is  in  an  inflammation  of  the  investing  or 
lining  membrane,  which  spreads  to  the  lacunae  of  the  bone,  thus 
producing  osteitis,  which  eventually  reaches  the  point  of  entire 
inhibition  of  nutrient  currents,  with  subsequent  death  of  a  territory 
more  or  less  extensive. 

Necrosis  is  usually  an  indication  of  a  weak,  anemic,  or  debili- 
tated condition.  When  all  the  functions  of  life  are  active  and 
general  nutrition  is  good,  vitality  in  a  part  will  be  maintained 


NECROSIS.  199 

despite  iinfavoring  conditions.  But  when  there  are  defects  in  the 
assimilative  process  retrogression  is  easy,  and  there  is  a  predis- 
position to  wasting  diseases.  The  most  fruitful  source  of  necrosis 
of  the  maxillae  will  be  found  in  the  presence  of  decayed,  diseased, 
irritating  roots  of  teeth.  These  initiate  inflammations,  and  exacer- 
bate them  when  once  started,  prevent  nutrition,  and  hence  provoke 
devitalization.  When  the  suppuration  of  alveolar  abscess  takes 
place  the  pus  may  burrow  beneath  the  periosteum  of  the  bone,  and, 
separating  it,  cut  off  nutrient  currents  from  the  territory  beneath. 
This  will  be  especially  probable  in  the  lower  jaw,  for  drainage  of  its 
pus  pockets  is  usually  imperfect,  while  gravity  constantly  tends  to 
bring  about  infiltration ;  and  this  will  in  part  account  for  the  greater 
proportion  of  cases  of  necrosis  in  that  bone. 

A  fruitful  cause  for  necrosis  of  the  jaws  will  be  found  in  im- 
pacted teeth,  arising  from  the  lack  of  room  for  their  proper  develop- 
ment. This  is  especially  true  of  the  third  molars,  the  body  of  the 
jaw  between  the  symphysis  and  the  ascending  ramus  often  being 
too  short  to  afiford  room  for  all  the  teeth.  When  the  time  comes 
for  the  development  and  eruption  of  the  wisdom  tooth  all  the 
space  is  occvipied ;  it  is  imbedded  in  the  tissues  without  power  to 
advance,  and  becomes  a  source  of  violent  irritation.  An  inflamma- 
tion is  excited  which  assumes  a  peculiarly  vicious  character,  arid, 
the  irritant  still  remaining,  there  is  breaking  down  of  tissue,  infec- 
tion, and  suppuration.  In  the  general  degenerative  state  this 
spreads  to  the  bone,  with  consequent  acute  osteitis  and  necrosis. 
This  condition,  to  which  the  upper  jaw  is  not  as  liable,  yet  further 
accounts  for  the  disparity  in  the  relative  number  of  cases  in  the 
two  jaws. 

Necrosis  may  also  be  the  result  of  injuries  done  by  the  dentist. 
Fractures  of  the  alveolus  in  extraction  are  very  common,  but  such 
is  the  recuperative  power  of  these  very  vascular  bones  that  nature 
usually  buries  the  faults  of  the  incompetent  or  reckless  operator 
beneath  new  formations.  If,  however,  the  patient  is  suffering  from 
any  form  of  atony,  the  reparative  process  may  not  be  sufficiently 
active  to  restore  the  normal  condition,  and  retrogression  may  take 
the  place  of  progression.  In  such  patients  the  mere  careless  punc- 
ture of  the  alveolus  to  some  depth  by  a  sharp-pointed  excavator,  or 
plugger,  or  engine  bur  that  has  been  infected  by  some  septic 
product,  may  produce  inoculation  that  will  result  in  serious  necrotic 


200 


ORAL    PATHOLOGY    AND    PRACTICE. 


complications.  Arsenous  acid,  when  used  in  too  great  quantity  for 
the  devitahzation  of  a  tooth  pulp,  or  if  not  securely  sealed  in  the 
cavity  of  decay,  may  penetrate  to  the  alveolus  and  produce  a 
necrotic  condition  that  will  spread  to  other  tissues. 

The  pericemental  inflammations  consequent  upon  the  death  and 
infection  of  the  dental  pulp  are  a  fruitful  source  of  necrosis  of  the 
alveoli  and  maxillae.  As  has  been  elsewhere;  asserted,  these  always 
induce  an  osteitis  more  or  less  severe,  and  when  the  irritation  is 
continuous,  as  in  the  case  of  atonic  patients,  it  may  very  readily 
result  in  death  of  the  adjacent  bony  tissue.  The  premature  filling 
of  the  roots  of  septic  teeth  by  the  dentist  has  been  responsible  for 
many  cases  of  necrosis.     The  introduction  of  the  filling  before  the 

Fig.  fd. 


Necrosis  of  Tibia,  showing  Cavities  in  the  Bone. 


septic  state  shall  have  been  completely  made  aseptic,  and  before  the 
healing  process  has  been  fairly  initiated,  tends  to  keep  up  an  irrita- 
tion which  is  fatal  to  healthy  functional  activity. 

Certain  zymotic  and  exanthematous  diseases  sometimes  have 
necrosed  conditions  among  their  sequelae.  This  is  especially  true  of 
scarlet  fever.  Mercury,  when  given  in  large  doses,  may  cause  it. 
Tertiary  syphilis  is  quite  likely  to  attack  the  palate  and  nasal  bones. 
People  who,  having  dead  teeth,  work  in  match  factories,  are  espe- 
cially liable  to  a  form  of  affection  called  phosphor-necrosis,  caused 
by  the  fumes  of  the  phosphorus  used,  which  is  supposed  to  pene- 
trate through  the  root  canal,  and  thus  to  come  in  contact  with  the 
pericementum  which  gives  nutriment  to  the  alveolar  sockets.  So 
universally  is  this  special  condition  recognized,  that  in  France  every 
factory  that  uses  phosphorus  in  the  manufacture  of  matches  must 
employ  a  dentist,  whose  duty  it  is  periodically  to  examine  all  the 
inmates  and  forbid  the  employment  of  any  that  have  dead  teeth 
with  unfilled  roots. 


NECROSIS.  201 

The  diagnostic  signs  of  necrosis  are  usually  distinct  and  well 
marked.  With  the  death  of  the  bone,  the  overlying  tissues  with 
which  it  is  invested  become  pecuHarly  turgid  and  inflamed.  They 
finally  assume  a  characteristic  purple  tint,  and  look  exceedingly 
angry.  This  is  increased  as  the  tissue  commences  to  break  down 
beneath  the  surface  and  suppuration  ensues.  There  is  little  of  the 
characteristic  "pointing"  of  alveolar  abscess,  but  the  pus  finds  its 
way  to  the  surface  at  a  number  of  places,  and  the  discharge  is 
usually  profuse  and  fetid.  If  now  an  explorer  is  passed  into  one  of 
the  sinuses  until  it  reaches  the  bottom,  the  characteristic  sensation 
imparted  by  dead  bone  will  be  plainly  felt;  or  if  the  disease  has  been 
peculiarly  active  in  its  character  deep  cavities  may  be  detected  in 
the  bone,  with  crumbling,  disintegrating  edges.  (See  Fig.  54.) 
Minute  chips  of  the  degenerated  bone  may  be  easily  separated 
with  any  appropriate  instrument.  There  will  be  the  usual  septic 
fever,  and  this  may  be  decidedly  pronounced.  There  will  be  a 
general  malaise  and  loss  of  strength  and  vitality. 

The  constant  tendency  on  the  part  of  nature  is  to  get  rid  of  the 
dead  and  irritating  tissue.  The  very  suppuration  that  accompanies 
all  necrosed  conditions  is  a  part  of  this  process.  It  is  indicative  of 
a  disposition  to  slough  away  the  diseased  portion.  Sometimes  this 
is  successful.  There  is  a  clear  line  of  demarkation  drawn  between 
the  dead  and  the  living  tissue,  and  the  granular  lymph  acts  as  a 
kind  of  wedge  to  separate  them.  If  this  is  accomplished,  the  dead 
part  that  is  thrown  ofif  is  called  tlic  Seqiicstrinn.  At  the  same  time 
there  will  perhaps  be  a  successful  effort  on  the  part  of  nature  to 
reproduce  the  bone,  and  this  ma}^  be  outside  of  and  envelop  the 
sequestrum.  Such  new  enveloping  bone  is  called  the  Involncniin, 
and  it  may  entirely  prevent  the  exfoliation  of  the  secjuestrum.     (See 

Fig-  55-) 

When  there  is  extensive  alveolar  necrosis  of  a  peculiarly  active 
type  it  is  not  always  judicious  to  extract  teeth,  even  though  they 
are  plainly  involved.  There  is  a  difference  of  opinion  upon  this 
point  among  pathologists,  but  it  must  be  evident  to  all  that  if  the 
disease  is  the  result  of  an  acute  osteitis,  and  the  attachment  of  any 
part  of  a  tooth  is  in  live  bone,  its  extraction  will  produce  a  wovmd 
that  will  be  certain  of  infection ;  the  inflammation  will  spread  and  a 
new  focus  will  have  been  produced,  which  might  have  been  avoided 
had  the  tooth  been  left  to  the  slower  process  of  exfoliation.     On 


202 


ORAL    PATHOLOGY    AND    PRACTICE. 


the  Other  hand,  if  the  tooth  is  a  distinct  irritant  that  is  aggravating 
the  situation  it  should  be  removed,  provided  it  may  safely  be  done. 
It  will  therefore  be  seen  that  it  sometimes  requires  the  nicest  dis- 
crimination to  determine  this  point. 

If  there  is  a  tendency  toward  the  formation  of  a  sequestrum,, 
the  dentist  should  not  be  precipitate  in  attempting  its  removal. 
He  naturally  desires  to  hasten  this  process,  but  good  judgment 
must  be  employed,  and  it  is  usually  safest  to  await  the  exfoliation 
which  will  follow  in  due  time.     If  it  is  violently  torn  away  before 


Fig.  55. 


Necrosis  of  Humerus,  showing  Sequestrum  and  Involucrum,  the  One  Found 
Within  the  Other. 

the  separation  of  the  dead  from  the  living  tissue  is  completed 
by  nature  an  open  wound  is  produced,  as  in  the  case  of  extraction 
of  a  tooth,  and  at  this  point,  minute  though  it  may  be,  inflammation 
may  begin  anew  and  the  diseased  state  thus  be  aggravated.  But 
when  a  fissure  of  separation  can  be  felt,  a  pledget  of  antiseptic  cot- 
ton or  gauze  may  be  crowded  in,  and  thus  a  little  pressure  made  to 
assist  the  process  of  exfoliation. 


CHAPTER  XLIV. 


TREATMENT  OF  NECROSIS. 


The  treatment  of  necrosed  conditions  may  be  divided  into  three 
parts, — local,  operative,  and  general.  The  first  will  consist  of  the 
use  of  disinfectants  and  depurators.  There  will  be  little  occasion 
for  antiseptics,  because  the  flow  of  pus  cannot  be  prevented  as  long 
as  there  is  dead  bone.  But  the  whole  diseased  territory  should  be 
kept  as  carefully  drained  as  possible,  and  it  should  be  frequently 
and  efifectually  cleansed  with  some  good  disinfectant.     For  this 


TREATMENT    OF    NECROSIS.  203 

purpose  electrozone,  or  meditrina,  will  be  found  especially  useful,  or 
peroxide  of  hydrogen,  or  a  three  per  cent,  solution  of  pyrozone 
may  be  injected  with  a  syringe  or  applied  with  an  atomizer.  If 
the  discharge  of  pus  is  into  the  mouth,  that  cavity  should  be  fre- 
quently washed  with  an  antiseptic  gargle,  and  as  much  care  as  pos- 
sible should  be  exercised  to  avoid  swallowing  the  septic  products. 
A  drainage  tube,  or  strip  of  iodoform  gauze  to  serve  as  such,  may 
be  introduced  into  the  sinus  if  its  location  is  such  as  to  demand  it, 
and  this  may  be  held  in  place,  if  practicable,  with  strips  of  adhesive 
plaster.  Of  course,  neither  of  these  will  be  appropriate  if  the  dis- 
charge is  within  the  oral  cavity. 

Sulphuric  acid  may,  in  some  instances,  be  profitably  employed 
to  dissolve  out  the  dead  bone.  It  may  be  used  in  such  strength  as 
the  nature  of  the  case  demands,  from  a  dilute  aromatic  solution  to 
the  chemically  pure.  Of  course  the  latter  will  only  be  employed 
with  caution.  There  is  no  danger  to  the  soft  tissues  involved, 
unless  possibly  from  the  chemically  pure,  and  even  that  involves 
no  serious  effect  if  it  is  properly  used  and  washed  away  in  tim^. 
Local  stimulants  may  be  employed  to  overcome  the  indolence  if 
necessary. 

The  operative  measures  to  be  employed  will  consist  of  those 
necessary  to  secure  perfect  drainage,  and  operations  for  the  re- 
moval of  the  dead  bone.  Sometimes  in  the  lower  jaw  a  deep  pocket 
will  be  formed  in  the  body  of  that  bone,  through  the  enlargement 
by  necrosis  of  the  socket  of  a  tooth  which  was  the  original  cause  of 
irritation.  Drainage  of  this  may  be  impossible,  through  the  in- 
ability of  the  tissues  to  expel  the  pus  over  the  borders. 

In  one  such  case  the  author,  against  his  own  better  judgment 
but  at  the  solicitation  of  both  the  patient  and  the  dentist  who  had 
referred  her  to  him,  attempted  in  vain  the  acid  treatment  after  thor- 
ough burring  out  of  the  necrosed  cavity.  The  pocket  could  not  be 
kept  clean,  and  reinfection  from  the  retained  pus  was  certain, 
until  an  anesthetic  was  given  and  an  opening  made  from  outside 
the  face  and  beneath  the  jaw  into  the  cavity.  A  strip  of  iodoform 
gauze  was  then  passed  through  into  the  mouth,  drawn  back  and 
forth  repeatedly,  and  the  end  finally  left  projecting  from  the 
e'xternal  wound  to  assist  in  drainage.  The  result  was  a  speedy  and 
complete  cure,  without  the  use  of  any  other  agents.  In  some  cases 
of  necrosis  of  the  upper  jaw,  operative  measures  may  be  necessary 


204  ORAL    PATHOLOGY    AND    PRACTICE. 

to  open  completely  and  straighten  out  the  sinus  of  discharge.  This 
may  be  readily  done  by  a  proper  bur  in  the  dental  engine. 

The  operation  for  the  complete  removal  of  dead  bone  in  the 
maxillae  may  be  of  a  formidable  character,  and  its  consideration 
properly  belongs  to  the  domain  of  oral  surgery.  It  must  be  thor- 
oughly done,  if  done  at  all.  Half-way  operative  measures  are  of 
little  account.  The  patient,  having  been  properly  fortified  with 
nourishing  food  for  a  time,  is  anesthetized  and  placed  in  such  a 
position  as  will  afford  complete  command  of  the  situation.  The 
superincumbent  tissues  are  laid  back  by  the  proper  incisions,  the 
blood  checked  by  ligatures  or  the  use  of  hemostatic  forceps,  and 
the  territory  carefully  sponged  and  examined.  When  the  extent 
of  the  lesion  is  fully  determined,  the  proper  steps  are  taken  for  the 
removal  of  the  dead  and  diseased  bone  by  the  use  of  the  dental 
engine,  bone  chisels,  scrapers,  and  saws.  When  this  is  completed, 
all  exposed  edges  of  bone  must  be  made  smooth,  every  particle  of 
debris  removed,  and  the  wound  antiseptically  washed  and  properly 
closed,  with  sutures  if  necessary,  a  drainage  tube  inserted,  the 
exterior  dusted  with  iodoform  powder,  and  the  whole  enveloped  in 
the  proper  bandages  and  dressings.  If  the  wound  is  wholly  within 
the  oral  cavity,  of  course  the  iodoform  dusting  and  the  bandaging 
will  not  be  called  for.  The  desirability  of  working  within  the 
mouth  when  practicable  cannot  be  too  strongly  urged,  especially  in 
the  case  of  young  women,  that  disfigurement  may  not  be  the  result; 
but  the  success  of  an  operation  should  not  be  jeopardized  in  the 
eft'ort  to  avoid  minor  disfigurement.  A  visible  scar  is  better  tlian 
death,  or  even  the  entire  loss  of  a  bone. 

General  or  systemic  treatment  is  called  for  in  almost  every  case 
of  extensive  necrosis.  The  disease  is  of  such  a  wasting  nature  that, 
at  the  very  least,  tonics  and  a  sustaining  diet  will  be  called  for. 
The  patient  should  be  made  to  live  out  of  doors  as  much  as  pos- 
sible, and  every  hygienic  precaution  be  taken.  If  the  lesion  is  the 
result  of  some  cachectic  condition,  like  syphilis  or  mercurialization, 
the  general  treatment  proper  to  such  condition  must  be  instituted. 
For  the  former  a  strict  course  of  specific  treatment  will  be  de- 
manded. The  subject  is  presented  in  another  chapter,  and  hence 
it  is  not  necessary  to  pursue  it  farther  in  this  connection. 

The  tonics  that  are  used  in  wasting  diseases  are  of  two  kinds, — 
vegetable  and  mineral.     The  former  consist  mainly  of  the  bitter 


HYPERSEXSITl\li    DEXTIXE.  205 

barks  of  certain  trees,  while  the  latter  are  inorganic  substances  that 
exercise  a  peculiarly  stimulant  or  alterant  action  that  tends  to  pre- 
vent waste  or  assist  nutrition.  (Jf  the  veg-etable  tonics,  Peruvian 
bark  or  cinchona,  quassia,  gentian,  and  wild  cherry,  with  their  alka- 
loids, are  those  most  commonly  employed;  while  the  inorganic  or 
mineral  agents  most  used  are  preparations  of  iron,  of  copper,  and 
of  zinc,  with  such  other  remedies  as  subnitrate  of  bismuth  and  sul- 
phuric, nitric,  hydrochloric,  and  oxalic  acids. 


CHAPTER  XLV. 
HYPERSENSITIVE  DEXTTXE. 


Were  it  possible  to  rob  operative  dentistry  of  the  horrors  too 
often  its  determined  attendant  in  the  pain  and  anguish  that  excava- 
tion of  carious  teeth  causes,  public  health  would  be  greatly  con- 
served and  human  life  would  be  correspondingly  lengthened,  because 
of  the  greater  care  that  would  be  bestowed  upon  those  organs. 
A\'ould  the  public  generally  learn  to  look  upon  the  dentist  in 
his  true  light, — that  of  one  whose  mission  it  is  to  avert  pain  and 
suffering, — he  would  be  regarded  with  much  greater  favor-  and 
would  enjoy  higher  consideration.  But  the  nature  of  his  work  is 
such  that,  like  the  general  surgeon,  in  his  efforts  to  forestall  future 
anguish  he  too  often  brings  present  distress,  and  too  manv  who 
should  be  his  patients  choose  to  postpone  the  evil  day  and  hazard 
all  the  future  rather  than  risk  a  moment  of  the  present. 

Recognizing  all  this,  dentists  from  the  earliest  period  in  the 
history  of  their  art  have  been  constantly  striving  to  devise  some- 
thing that  will  give  exemption  from  pain  in  dental  operations. 
Most  of  their  efforts  have  been  entirely  empirical,  and  often  experi- 
ments and  labors  have  been  conducted  in  a  haphazard  way  that 
betokens  anything  but  professional  erudition  or  scientific  knowl- 
edge. Those  who  have  claimed  to  accomplish  anything  in  the  way 
of  a  solution  of  the  problem,  have  not  usually  been  those  who  were 
best  equipped  by  education  and  professional  attainments  for  the 
task.  The  practitioner  who  advertises  "painless  dentistry"  has 
passed  into  a  byword,  and  the  term  is  a  synonym  for  an  impostor 
and  a  charlatan.     Almost  invariably  those  who  have  brawlingly 


206  ORAL    PATHOLOGY    AND    PRACTICE. 

boasted  that  they  have  discovered  a  universal  panacea  for  all  dental 
pain  have  been  illiterate,  undisciplined,  unknown  pretenders,  whose 
sole  object  was  to  secure  a  dirty  dollar  by  unprofessional  methods, 
and  to  make  profit  out  of  that  which  should  be  public  philanthropy; 
men  who  would,  if  possible,  garner  the  sun's  beams  and  peddle 
them  out  for  individual  gain;  who  would  put  holy  things  to  an 
unholy  use,  and  make  of  human  beneficence  a  public  prostitute. 
Of  this  character  have  been  most  of  the  widely  advertised  prepara- 
tions for  obtunding  the  dental  tissues, — quack  remedies,  prepared 
by  dental  quacks  for  quackish  purposes.  The  student  and  practi- 
tioner should  avoid  them  if  he  is  an  honest  man,  for  he  has  no 
moral  right  to  recommend  to  a  patient,  who  pays  him  for  special 
knowledge,  any  drug  of  whose  exact  nature  and  therapeutic  value 
both  are  alike  ignorant. 

In  its  normal  condition  dentine  should  be  without  sensation. 
There  are  no  organized  nerves  to  convey  impressions,  even  were  the 
tooth-bone  subject  to  them.  Yet  the  protoplasmic,  albuminoid  con- 
tents of  the  dental  tubuli  may,  under  special  irritation,  become 
the  subjects  of  inflammatory  conditions,  in  which  they  not  only  re- 
ceive, but  readily  transmit  to  the  dental  pulp,  external  impulses 
of  a  painful  nature.  (See  Fig.  56.)  It  is  true  that  the  pulp  of  the 
tooth  is  supplied  with  nerves ;  yet  they  are  without  some  of  the 
characteristics  of  ordinary  nerves,  and,  protected  from  all  irritating 
shocks  as  it  is  in  its  normal  state,  even  the  pulp  is  not  of  itself 
responsive.  Only  when  some  of  its  protection  is  withdrawn,  or 
when  from  some  reflex  source  the  pulp  is  subjected  to  special 
irritation,  does  it  become  impressible  to  outward  agencies  and  con- 
vey disagreeable  sensations. 

We  know  that  it  is  a  law  that  animals,  and  organs  and  tissues, 
adapt  themselves  to  their  environments  and  change  their  structure 
with  varying  conditions.  Thus  the  fishes  of  rayless  caverns  lose 
their  sight,  and  certain  inhabitants  of  the  greatest  ocean  depths  are 
without  the  usual  sensory  functions.  Both,  by  gradual  transmis- 
sion to  other  surroundings,  would  develop  special  senses,  as  have 
other  organisms.  Continual  subjection  to  external  irritation  may 
either  weaken  or  develop  the  corresponding  sentient  perceptive- 
ness,  through  which  alone  can  defense  and  security  be  obtained. 

That  both  dentine  and  dentinal  pulp  are  without  ordinary 
sensation  when  in  a  perfectly  healthy  and  normal  condition,  is 


HYPERSENSITIVE   DENTINE. 


207 


proved  by  the  fact  that  when  a  healthy  tooth  is  fractured  and  the 
pulp  thereby  completely  exposed,  it  is  irresponsive  to  external  irri- 
tants for  a  short  time.  Healthy  pulps  are  painlessly  "knocked  out" 
by  a  certain  class  of  practitioners,  provided  the  teeth  are  sound  and 
the  work  is  done  quickly  enough.  But  if  there  is  the  least  inflam- 
mation in  either  pulp  or  dentinal  fibrils  the  operation  is  anything 
but  painless.  There  is  not  a  practitioner  of  extended  experience 
who  has  not  at  some  time  cut  into  the  dental  pulp  entirely  without 
the  knowledge  of  his  patient,  provided  he  was  excavating  in  dentine 
that  was  completely  or  even  comparatively  irresponsive. 


Fig.  56. 


# 


Formative  Dentine,  showing  the  Protoplasmic  Fibrill^e. 
a,  Odontoblast  cells  of  the  pulp,  with  Tomes  fibers  or  dentinal  fibrillse  ;   6,  Forming  dentine. 
c,  Formed  dentine  cut  diagonally  across  the  tubules.     (Andrews.) 

The  source  of  sensitive  dentine,  or  of  impressionable  pulps,  lies 
in  their  continued  subjection  to  irritation,  by  which  responsiveness 
is  developed.  The  freshly  exposed  pulp,  or  dentine,  of  a  perfectly 
healthy  tooth,  is  without  sensation.  But  a  few  moments  of  subjec- 
tion to  external  influences,  the  air  and  other  irritants,  are  sufficient 
to  produce  a  marked  change  in  the  tissues,  and  they  become 
exquisitely  responsive.  A  kind  of  inflammatory  degeneration 
takes  place,  and  normal  function  is  so  altered  that  disagreeable 
currents  are  conveyed.     This  is  in  perfect  harmony  with  the  other 


208  ORAL    PATHOLOGY    AND    PRACTICE. 

known  processes  of  Nature,  for  in  the  presence  of  danger  she 
always  develops  means  of  defense  by  giving  warning  through  the 
awakened  senses. 

If,  then,  in  the  normal  state  the  tooth  tissues  are  without 
sensation,  it  follows  that  if  a  pathological  condition  is  succeeded 
by  one  of  perfect  health,  the  immunity  to  pain  should  be  re-estab- 
lished. This  is  undoubtedly  the  fact,  for  teeth  that  have  been 
attacked  by  caries,  and  which  under  its  influence  have  become 
painfully  sensitive,  have,  when  the  broken  continuity  has  been 
restored  by  a  filling,  lost  that  responsiveness  and  again  become 
insusceptible  to  external  impression.  It  is  true  that  this  is  not 
always  the  case,  because  the  very  material  that  has  been  used  to 
mend  the  broken  place  may  of  itself  become  an  irritant  and  per- 
petuate the  abnormal  state.  Were  it  possible  to  fill  an  ordinary 
tooth  with  something  that  would  be  perfectly  congenial  to  the 
tissues,  there  is  little  doubt  that  all  filled  teeth  would  be  comfort- 
able, and  herein  may  be  foand  a  reason  why  certain  materials, 
aside  from  their  lasting  qualities,  make  the  best  fillings. 

The  test  for  the  perfect  success  of  an  operation  is  the  condition 
of  the  tissues  which  ensues, — because  recurrent  decay  is  not  the 
first  symptom  of  the  failure  of  an  operation.  It  may  be  found  in  the 
responsiveness  of  the  dentine  to  external  irritants ;  in  its  sensitive- 
ness to  outward  impressions.  Not  that  it  is  always  possible  com- 
pletely to  restore  to  healthy  functional  activity  a  tooth  that  has 
been  subjected  to  operative  filling.  Usually  only  toleration  with 
mild  protest  can  be  obtained  for  the  foreign  matter  that  is  ttsed 
for  protective  purposes,  especially  if  it  is  of  a  metallic  nature. 
When  there  is  permanent  denudation  of  any  part,  as  in  recession 
of  the  gums,  normal  conditions  cannot  even  be  approximated. 

One  of  the  causes  of  the  irritation  in  which  is  found  the  source 
of  sensitive  dentine  is  caries.  This  is  of  itself  a  pathological  con- 
dition of  dentine,  and  its  progress  necessarily  entails  other  degen- 
erative conditions.  The  disintegration  of  portions  of  the  tooth- 
bone,  with  the  consequent  destruction  of  parts  of  the  dental  fibrill?e, 
must  affect  that  with  which  it  is  in  connection ;  and  so  there  will  be 
an  irritable,  disordered  condition  of  the  whole  of  the  dentine,  with 
hypersensitiveness  and  inflammatory  changes  in  the  protoplasmic 
_.  .elements  of  the  soft  fibrils,  inodified  in  manifestation  by  the  char- 
^^cter  of  the  structure  itself.'    Witfi''such  a  destructive,  deadly  dis- 


i&&. 


HYPERSENSITIVE   DENTINE.  2O9 

order  as  caries  working  at  its  vitals,  no  portion  of  the  structure  of  a 
tooth  can  be  in  a  healthy  state,  for  although  teeth  have  not  the 
complex  and  vascular  formation  of  the  soft  tissues,  we  cannot  con- 
sider these  organs  as  made  up  of  dead,  inert  matter. 

Denudation  of  portions  of  the  tooth,  its  loss  of  a  part  of  that 
which  should  form  any  of  its  investing  protection,  must  subject  it 
to  unnatural  conditions.  If  the  gum  has  receded  at  the  neck,  that 
simply  means  that  the  tooth  is  exposed  to  new  environments  and 
strange  perplexities  that  cannot  be  otherwise  than  exasperating. 
Under  the  stress  of  their  provocation  it  assumes  an  added  sus- 
ceptibility, and  becomes  more  and  more  liable  to  attacks  of  external 
agents.  All  the  dentine  is  thus  affected,  and  it  becomes  tender, 
sensitive,  responsive  to  any  provocation.  This,  as  in  the  case  of 
caries,  proceeds  by  continuity  of  tissue  to  the  pulp,  which  also 
becomes  irritable  and  inflamed,  so  that  there  is  an  immediate 
response  to  thermal  changes,  to  the  presence  of  acids  or  sweets, 
and  even  to  the  finger  nail  or  quill  toothpick.  Metal  toothpicks  are 
almost  always  irritating  to  the  teeth. 

Vitiated  secretions  are  also  a  cause  of  sensitive  dentine. 
The  secretion  of  the  somewhat  specialized  mucous  follicles  at  the 
gingival  margin  is  sometimes,  through  neglect  of  the  teeth  and  the 
presence  of  fermenting  debris,  of  a  degenerative  type.  This  secre- 
tion becomes  acid,  and  in  this  state  is  highly  irritative  to  the  cervix 
of  the  tooth.  Or  the  white  deposit  which  is  so  frequently  found 
surrounding  the  tooth  at  its  neck,  and  which  is  made  up  of  decom- 
posing matter  undergoing  fermentation  or  putrefaction,  may  be  the 
cause  of  the  irritation.  The  resulting  acid  may  dissolve  out  some 
of  the  lime  salts  at  the  cervix,  where  the  enamel  is  very  thin,  and  so 
lay  bare  the  dentine,  which  will  thus  be  made  specially  irritable. 
Some  of  the  most  sensitive  dentine  encountered  by  the  operator  is 
the  result  of  this  acid  degeneration  or  formation. 

The  teeth  are  sometimes  set  on  edge  by  the  use  of  acids. 
This  means  softening  of  the  superficial  portion  of  the  tooth,  and  a 
hyperesthesia,  or  its  analogue,  of  the  dentine.  The  sensation 
referred  to  is  not  a  distinct  pain,  and  it  usually  passes  away  with 
the  provocation,  but  it  is  a  definite  feeling  of  responsiveness  in 
dentine.  The  same  kind  of  impression  may  be  induced  by  reflex 
action,  when  a  saw  is  filed  or  strong  cloth  is  torn. 

15 


210  ORAL    PATHOLOGY   AND   PRACTICE. 

CHAPTER  XLVL 

TREATMENT  OF  HYPERSENSITIVE  DENTINE. 

It  has  been  affirmed  that  if  a  tooth  that  is  in  a  healthy  condi- 
tion is  insensitive,  a  return  to  that  state  after  diseased  action  should 
carry  with  it  freedom  from  responsiveness.  While  this  may  be 
true,  it  is  not  always  possible  in  dental  practice  to  secure  this  result. 
In  cases  of  caries  it  is  impossible  to  induce  a  healthy  state  except 
by  excision  of  the  diseased  part,  as  in  necrosis  of  bone;  and  it  is 
from  the  pain  of  that  operation  that  we  seek  immunity ;  hence  the 
only  hope  of  the  dentist  is  in  securing  an  artificial  anesthesia  of  the 
part.  This  may  be  readily  accomplished,  as  in  the  other  tissues,  by 
inhibiting  and  stopping  all  nervous  currents  through  general  anes- 
thesia. But  such  methods  are  prohibited  by  the  circumstances  of 
the  case.  We  do  not  wish  to  obtund  all  sensibility,  but  only  to 
overcome  that  of  a  small  part. 

The  ordinary  local  anesthetics  might  be  employed,  and  they 
would  completely  answer  all  demands  were  that  which  we  wish  to 
make  insensitive  supplied  with  bloodvessels  and  nerves.  Unfor- 
tunately for  our  object,  this  is  not  the  case  with  the  teeth.  Theirs 
is  not  the  structure  upon  which  local  anesthetics  act,  and  hence  the 
latter  are  of  but  doubtful  utility.  When  cocain  was  first  discovered 
it  was  believed  by  many  that  the .  dental  millennium  had  surely 
arrived,  but  that  agent  has  been  found  powerless  to  benumb  non- 
vascular tissues.  This  class  of  remedies  may  therefore  be  dismissed 
from  consideration,  because  while  they  may  under  certain  condi- 
tions inhibit  nervous  currents  in  tissues  that  have  a  nervous  supply, 
they  are  inefficacious  when  that  is  lacking.  Cocain  will  obtund  a 
pulp  that  is  exposed  to  its  influence,  but  it  is  ordinarily  powerless 
upon  dentine. 
■  ',,  We  are  thus  obliged  to  fall  back  upon  specific  remedies,  or 
those  whose  therapeutic  action  is  not  thus  limited.  We  know  that 
the  protoplasmic  dentinal  fibrils,  when  in  an  irritable  state,  or  when 
made  responsive  by  certain  pathological  conditions,  will  convey 
painful  impulses  along  their  course  and  deliver  them  to  the 
cerminal  nerve  filaments  of  a  more  or  less  inflamed  pulp.  If,  now, 
these  afferent  waves  of  irritation  can  be  cut  off  at  any  point  before 
rcrxi'.inrj  the  sentient  centers,  immunity  from  pain  will  thereby  be 


TREATMENT   OF    HYPERSENSITIVE   DENTINE. 


211 


secured.  This  can  be  done  by  a  general  anesthetic  that  paralyzes 
sensory  filaments  and  trunks,  or  it  could  be  accomplished  by  the 
application  of  a  local  anesthetic  directly  to  the  pulp  itself.  Both  of 
these,  for  reasons  already  given,  are  impracticable,  and  it  leaves  the 
work  to  be  done  upon  the  only  other  connecting  link  between  the 
dentinal  periphery  and  the  brain. 

If  the  dental  fibrils  themselves  can  be  put  in  such  a  state  that 
they  will  no  longer  carry  impulses  to  the  pulp,  that  tissue  cannot 
transmit  any  to  the  afferent  nerves  which  carry  them  to  the  nerve 

centers. 

Fig.  57. 


Termination  of  the  Dentinal  Tubuli. 
a,  Enamel;  b,  Dentine;  c,  Line  of  junction  of  enamel  and  dentine, — first  calcification  of  tooth 
tissue;  interglobular  spaces.     (Andrews.)- 

There  are  two  ways  of  accomplishing  this,  neither  of  which  is 
entirely  satisfactory  in  its  results.  The  first  is  by  producing  some 
temporary  physical  change  in  the  character  of  the  fibril  that  will 
prevent  its  receiving  an  impulse,  and  the  second  by  subjecting  it  to 
some  medicinal  agent  that  will  paralyze  its  transmitting  function. 

There  are  perhaps  two  other  methods  of  accomplishing  the 
same  thing  which  should  be  included  in  the  list  of  methods  to  be 
employed,  and  they  will  be  duly  considered.  They  are,  first,  the 
exercise  of  such  care  and  gentleness,  with  the  use  of  such  perfected 
instruments  as  shall  arouse  no  irritating  pain  waves;  and,  second, 
the    employment    of    such    general    prophylactic    remedies    and 


212  .    OliAL    PATHOLOGY   AND    PRACTICE. 

measures  to  fortify  the  system  as  will  enable  it  to  resist  them, 
or  steel  it  against  their  reception. 

The  physical  agents  which  are  practicable  will  be  such  as  will 
temporarily  change  the  material  characteristics  of  the  fibrillse,  and 
of  these  the  most  important  are  heat  and  cold. 

Heat  may  act  either  by  raising  the  temperature  above  the  point 
of  susceptibility, — which  is  impracticable,  because  it  is  of  itself  a 
painful  process, — or  by  so  changing  the  matter  of  the  fibrillse 
through  desiccation,  or  drying  out,  as  to  make  them  incapable  of 
conveying  impulses.  It  is  readily  conceivable  that,  a  cavity  being 
isolated  by  the  use  of  a  rubber-dam,  a  current  of  hot  air  may  be 
effectual  in  so  changing  the  physical  structure  of  a  fibril,  by 
abstracting  a  part  of  its  water,  as  to  debar  all  reception  or  trans- 
mission of  nervous  or  other  impulses.  This  is  perhaps  the  most 
simple  of  all  methods  for  obtunding  sensitive  dentine. 

The  use  of  cold,  or  refrigeration,  will  be  equally  effectual  by 
benumbing  or  paralyzing  the  fabrillse.  If  an  ether  or  rhigolene 
spray  is  directed  upon  the  tooth  cavity,  or  even  upon  the  tooth 
itself,  until  the  temperature  is  reduced  sufficiently,  it  will  be  com- 
paratively irresponsive.  This  would  without  doubt  be  the  most 
perfect  obtundent,  were  it  not  that  the  effective  use  of  the  agent 
is  of  itself  too  painful  in  its  application.  There  is  also  danger  that 
the  pulp  tissue  may  be  permanently  injured  through  degenerative 
processes  inaugurated  by  the  shock  of  the  cold.  A  severe  inflam- 
mation may  be  the  result  of  the  application  of  the  ether  spray  for 
too  long  a  time.  Hence  this  agent  has  never  been  used  for  obtund- 
ing purposes,  except  in  extreme  instances. 

The  medicinal  agents  that  have  been  employed  in  attempts  to 
overcome  dentinal  hypersensitiveness  are  almost  numberless. 
General  and  local  anesthetics,  stimulants  and  anodynes,  excitants 
and  sedatives,  acids  and  alkalies,  with  many  drugs  of  altogether 
indefinite  and  unknown  therapeutic  value,  have  been  persistently 
recommended.  The  whole  matter  has  generally  been  one  of 
empiricism.  It  would  seem  that,  so  far  as  our  present  knowledge 
goes,  anesthetics,  whenever  locally  applied,  have  little  direct  effect 
upon  dentinal  tissue.  All  such  remedies  have  a  selective  power, 
and  affect  nervous  tissue  alone.  The  dentinal  fibrillse,  while  they 
do  not  contain  any  nervous  filaments,  yet  comprise  the  elements  of 
such  tissue ;  and  it  cannot  be  positively  affirmed  that  they  are  not, 


TREATMENT    OF    HYPERSENSITIVE    DENTINE.  213 

under  certain  conditions,  amenable  to  anesthetic  action.  But  we 
know  that  they  are  not  ordinarily  so,  and  hence  the  agents  referred 
to  have  proved  as  inefficient  as  might  have  been  anticipated. 

Certain  sedatives,  anodynes,  and  narcotics,  like  preparations  of 
opium,  cannabis  indica,  and  chloral  hydrate,  have  been  effective  in 
certain  instances,  but  it  is  not  at  all  certain  that  they  did  not  work 
through  other  tissues,  and  thus  act  indirectly  instead  of  directly. 
Some  cauterants  are  effectual,  but  to  a  limited  depth.  Thus  nitrate 
of  silver,  or  chromic  acid,  or  carbolic  acid,  will  obtund,  but  only  to 
the  limited  depth  to  which  they  reach.  They  certainly  destroy  the 
fibrillge  completely  as  far  as  their  action  extends,  but  that  action  is 
not  really  obtunding ;  it  is  extinction. 

In  the  harmless  coagulation  of  the  albuminoid  contents  of  the 
dental  tubuli  would  seem  to  lie  the  surest  road  to  success. 

There  are  coagulating  agents  that  thus  obtund,  like  chloride 
of  zinc,  but  it  is  too  often  at  the  expense  of  quite  as  much  suffering 
as  they  save,  leaving  out  of  consideration  the  dangers  to  which 
the  dental  pulp  is  exposed  by  the  use  in  its  proximity  of  active 
escharotics.  If  coagulation  could  be  accomplished  without  per- 
manent injury  to  the  tooth  structure,  and  would  reach  deep 
enough  to  allow  of  eflfective  excavation,  the  agent  that  accom- 
plished this  without  pain  would  be  the  long-sought  desideratum. 
That  drug  has  not  yet  been  discovered,  nor  can  we  be  sure  that  it 
ever  will  be.  Certain  it  is  that  until  it  is  sought  for  in  an  intelli- 
gent, scientific  manner,  it  will  remain  a  secret;  for  the  illiterate, 
untaught  ignoramuses  who  have  in  the  past  been  mainly  respon- 
sible for  the  quack  preparations  sold  at  an  extortionate  price,  and 
who  have  not  sufficient  pharmacal  knowledge  to  save  them  from 
compounding  the  most  glaring  chemical  incompatibles,  are  not 
likely  to  be  the  discoverers  of  that  which  so  many  competent  men 
have  sought  in  vain. 

Cataphoresis,  which  is  the  transfer  of  medicaments  into  the 
deeper  parts  of  tissue  through  the  diffusive  power  of  an  electric 
current,  seems  to  promise  something  in  this  direction.  It  is  not 
recently  acquired  information  that  has  taught  us  that  when  a  drug 
is  applied  to  a  tissue  upon  the  positive  electrode  of  a  battery,  the 
negative  being  placed  so  that  the  current  will  traverse  the  organ 
to  be  afifected,  it  will  carry  with  it  the  remedy;  this  principle  has 
been  quite  extensively  employed  in  general  medicine,  and  with  good 


214  ORAL    PATHOLOGY    AND    PRACTICE. 

results.  To  make  the  remedy  in  cataphoric  medication  effective  it 
is  not  sufficient  to  carry  it  deeply  into  the  dentine ;  it  must  be  trans- 
ferred to  the  pulp  itself,  and  to  the  accomplishment  of  this  the  hard 
dental  tissues  present  difficulties  not  met  with  in  other"  organs,  in 
their  relatively  low  vitality  and  their  comparative  impenetrability. 
Yet  practical  experience  seems  to  point  to  the  indisputable  fact  that 
cataphoric  transference  does  take  place,  but  whether  with  sufficient 
readiness  and  rapidity  to  make  it  all  that  can  be  desired  remains  to 
be  definitely  established.  No  one  will  dispute  the  assertion  that  in 
the  cataphoric  transference  of  such  topically  applied  remedies  as 
cocaine  and  morphine  better  results  have  been  secured  than  in  any 
other  of  the  thousand  proffered  methods  of  obtunding  sensitive 
dentine.  But  its  employment  requires  a  cumbersome  and  expen- 
sive apparatus,  troublesome  alike  to  operator  and  patient,  and  its 
results  are  by  no  means  uniform.  While,  therefore,  every  progres- 
sive operator  should  use  it,  it  is  not  now  to  be  considered  a  finality. 
Its  application  must  be  simplified  and  its  effects  made  positive  by 
further  experimentation  before  it  can  be  so  accepted.  Good  men 
are  investigating  it,  and  it  is  to  be  hoped  that  in  it  will  eventually 
be  found  that  which  is  so  highly  desirable.  It  cannot  be  forgotten, 
however,  that  good  men  have  before  this  cried,  "Lo,  here!  Lo, 
there!"  only  to  meet  final  disappointment  and  defeat. 

Prophylactics  have  proved  of  great  service  in  the  dental  operat- 
ing room.  They  are  of  sedative  nature,  and  reduce  general  nervous 
irritability,  thus  preventing  or  obtunding  nervous  shock.  They 
have  not  been  as  much  used  as  their  merits  demand,  because  most 
dentists  have  either  been  lacking  in  the  medical  knowledge  neces- 
sary to  their  most  intelligent  use,  or  have  not  felt  themselves  war- 
ranted in  administering  general  remedies.  The  first  of  these 
causes,  if  it  exists,  should  be  at  once  removed  by  study,  and  the 
last  eliminated  by  a  proper  amount  of  self-confidence.  The  time 
for  administering  such  remedies  is  a  few  moments  before  com- 
mencing any  painful  operation,  the  exact  interval  depending  upon 
the  nature  of  the  drug.  A  few  whiffs  of  chloroform  or  ether,  not 
enough  to  induce  any  functional  disturbance  whatever,  will  fre- 
cj[uently  be  of  use,  but  their  influence  will  not  last  long.  Twenty- 
five  grains  of  potassium  bromide  in  water  will  be  more  persistent, 
and  usually  quite  as  effective.  Syrup  of  lactucarium,  in  teaspoon- 
ful  doses,  has  been  employed  with  good  effect ;  or  tincture  of  bella- 
donna, administering  from  five  to  twenty  drops. 


TREATMENT   OF    HYPERSENSITIVE   DENTINE.  21 5 

Sulphate  of  morphia,  in  doses  of  from  a  quarter  to  half  a  grain, 
has  been  frequently  used,  but  its  action  upon  some  people  is  a  little 
uncertain.  The  fluid  extract  of  Jamaica  dogwood  may  be  substi- 
tuted for  -this,  and  five  to  twenty  drops  given  in  a  little  water. 
The  full  dose  of  the  drug  is  from  a  half  to  two  fluidrams.  The 
author  has  not  for  several  years  been  without  aromatic  spirits  of 
ammonia  in  his  case,  and  whenever  there  is  unusual  nervous  irrita- 
bihty  he  administers  from  thirty  to  sixty  drops  of  it  in  water.  If 
there  arises  the  necessity,  a  hypodermic  dose  of  from  one-eighth  to 
a  quarter  of  a  grain  of  morphine  may  be  given.  This  is  usually 
effectual  in  quieting  all  nervous  excitability  and  making  otherwise 
insupportable  operations  comparatively  tolerable.  The  proper 
dose  of  this  drug,  combined  with  atropine  or  strychnine,  may  be 
readily  obtained  in  tablet  form,  and  should  always  be  kept  at  hand. 

Hypodermic  medication  has  not  been  as  much  employed  in 
oral  practice  in  the  past  as  it  should  have  been. 

But,  when  all  is  said  and  done,  the  main  dependence  of  the 
judicious  dentist  will  be  upon  a  gentle  hand  and  sharp  instruments. 
It  is  barbarous  to  employ  in  a  sensitive  tooth  any  tool  that  is  not 
in  the  best  possible  order;  while  the  operative  dentist  who  for  a 
moment  allows  himself  to  forget  the  consideration  that  is  due  to  a 
sensitive,  timid,  shrinking  patient,  who  will  become  in  the  least 
degree  careless  or  callous,  and  thus  give  unnecessary  pain,  is 
unworthy  his  vocation.  In  excavating  a  sensitive  tooth  he  should 
invariably  put  on  the  rubber-dam,  and  dry  out  the  cavity  as  far  as 
possible.  Then  he  will  find  a  great  deal  of  relief  in  the  employ- 
ment of  many  of  the  remedies  already  mentioned,  and  especially 
in  the  use  of  some  of  the  essential  oils,  like  cassia,  cloves,  or 
eucalyptus,  securing  penetration  by  means  of  the  hot-air  blast. 
A  mixture  of  equal  parts  of  sulphate  of  morphia  and  gum  camphor 
may  be  found  useful  for  this  purpose  in  some  instances.  Or  he 
may  apply  tincture  of  aconite  dilute,  or  any  other  favorite  remedy, 
always  remembering  that  its  effectiveness  will  be  greatly  increased 
by  thoroughly  drying  the  cavity  of  decay,  and  by  the  hot-air 
current. 

For  those  who  wish  a  cocain  preparation  that  is  effective,  the 
following  is  given.  It  should  not  be  forgotten  that  this  is  a  ten 
per  cent,  solution,  and  when  used  hypodermically  less  of  it  should 
be  injected: 


2l6  ORAL    PATHOLOGY    AND    PRACTICE. 

? — Atropine,  xV  grain; 

Strophanthine,  Vs       " 

Cocain  mur.,  50      " 

Carbolic  acid,  10      " 

Oil  of  caryophyllus,  3  minims  ; 

Dist.  water,  i  ounce. 

The  following  formula  has  been  recommended  by  Professor 

Peirce  as  effective: 

I? — Cocain  mur.,  5  grains; 

Carbolic  acid,  20      " 

Chloroform,  J^  dram; 

Muriatic  acid,  10  minims; 

Alcohol,  2  drams. 


CHAPTER    XLVII. 


SECONDARY   DENTINE,   PULP   NODULES,   AND 
CALCIFICATIONS. 

These,  although  different  manifestations,  are  parts  of  the  same 
process.  They  have  their  origin  in  the  same  disturbed  function. 
They  are  the  result  of  deranged  neural  currents  and  of  some  per- 
version of  nutrition  which  induces  a  formation  of  dentine  in  abnor- 
mal quantities  or  in  an  anomalous  position,  through  the  undue 
activity  of  the  odontoblast  cells  under  the  excitement  of  just 
enough  of  irritation  to  act  as  the  proper  stimulant.  All  of  these 
products  have  the  general  structure  of  dentine,  although  it  may  be 
considerably  modified.  (See  Fig.  58.)  They  are  not  usually 
found  as  mere  calcific,  structureless  calculi,  but  are  organized  by  the 
unduly  excited  odontoblast  cells,  whose  normal  activity  continues 
through  life. 

The  odontoblasts  are  not  found  exclnsively  upon  the  periphery 
of  the  dental  pulp,  any  more  than  osteoblasts  exist  alone  in  con- 
nection with  periosteum.  The  latter  may  be  found  inside  the  body 
of  the  bone,  and  may  be  the  initial  points  for  new  growths  after 
operations  or  accidents.  The  former  may  exist  or  be  developed 
within  the  pulp  tissue,  and  under  the  special  stimulus  that  was 
perhaps  responsible  for  their  formation  may  commence  functional 
activity,  with  the  consequent  organization  of  segregated  spicules  of 
dentine,  and  these  may  continue  to  grow  until  they  assume  the  form 


SECONDARY  DENTINE,   PULl'    NODL'EES,   AND  CALCIFICATIONS.       217 

of  the  usual  pulp  nodule.  Sometimes  this  form  of  calcification  may 
begin  at  many  points  within  the  pulp,  and  may  impart  to  that  of  a 
freshly  extracted  tooth  a  gritty,  sandy  sensation  when  it  is  rubbed 
between  the  finger  and  the  thumb.  At  other  times  there  is  an 
agglomeration  into  one  or  more  large  concretions. 

When  the  unwonted  functional  activity  is  at  the  peripheral 
pulp  borders,  the  new  formation  will  probably  be  attached  to  and 
form  a  kind  of  hypertrophy  of  the  ordinary  dentine  of  the  tooth. 
Sometimes  this  will  be  so  continued  that  it  will  almost  entirely  fill 

Fig.  58. 


Formation  of  Pulp  Stones.     (Andrews.) 


the  pulp  chamber,  and  even  extend  down  into  the  root  canal. 
An  examination  of  an  extracted  tooth  affected  with  this  condition 
will  show  by  its  complete  or  partial  attachment  to  the  normal 
dentine,  or  by  its  independence  of  it,  where  was  the  commencement 
of  the  new  growth. 

The  "pulp  stones,"  or  formations  of  dentine  that  take  place 
within  the  substance  of  the  pulp,  sometimes  contain  chambers  not 
unlike  the  "interglobular  spaces"  of  the  tooth.  These  impart  an 
appearance  of  bone,  and  the  new  formation  is  analogous  to  true 
"osteo-dentine."     It  niay  even  have  open  canals  that  cause  it  to 


2l8 


ORAL   PATHOLOGY   AND   PRACTICE. 


assume  the  appearance  of  vaso-dentine.     As  might  be  inferred  from 
the  circumstances  under  which  it  is  deposited,  its  structure  will  be 

Fig.  59. 


_ju»''^ 


Secondary  Formations  in  the  Tooth  of  a  Whale. 


Fig.  6o. 


Wounded  Tusk  of  Elephant. 


a,  Point  of  entrance  of  musket  ball  through  the  alveolar  walls  when  the  animal  was  young  ; 
b.  The  ball  carried  down  andimbeddedin  the  ivory  or  dentine  by  the  growth  of  the  tusk.  (From 
a  specimen  in  the  Buffalo  College  Museum.) 

quite  irregular  and   unmethodical.     The   canaliculi,   or   dentinal 
tubuli,  will  be  involved,  convolwted,  and  irregular.     More  or  less 


SECONDARY  DENTINE,   PULP   NODULES,   AND   CALCIFICATIONS.       219 

Fig.  6r. 


A    REPRESIiNTATlON   OF    THE   TuSK  SHOWN    I.N    l'  lu.    6o,   VVll  H    A    SliCTION    REMOVED   TO    SHOW 

Secondary  Formations  in  the  Pulp  Chamber  above  the  Ball. 
a,  Cervix  of  tusk  ;  6,  c,  d,  e,  Masses  of  secondary  formation. 


220 


ORAL    PATHOLOGY   AND   PRACTICE. 


of  the  calcified  mass  may  be  hyaline,  but  the  structure,  when  care- 
fully studied,  will  be  found  to  be  essentially  dentinal. 

The  study  of  comparative  dental  anatomy  will  materially 
assist  in  a  comprehension  of  these  anomalies.  In  certain  animals 
secondary  dentine,  or  tooth-bone,  is  very  common.  This  is 
especially  the  case  with  some  of  the  monophyodonts.  The  per- 
sistent pulp  chambers  of  the  sperm  whale  (Physeter  macrocephalus) 
are  very  frequently  lined  or  partially  filled  with  secondary 
dentinal  formations,  and  some  of  them  make  very  beautiful  objects 
when  polished.  (See  Fig.  59.)  The  long  incisors  of  the  elephant, 
the  so-called  tusks,  are  frequently  wounded  by  the  hunter  near  their 
insertion,  the  bullets  remaining  in  the  persistent  pulps.  This  may 
result  in  the  destruction  of  the  vascular  portion  of  the  tooth,  but 

Fig.  62. 


Fossil  Fragment  of  the  Tusk  of  Elephas  primigenius—TRK  Hairy  Mammoth — which 
had  been  partially  fractured  during  life  and  repaired  and  strengthened  by 
Secondary  Deposits. 

The  fracture  was  across  the  base  at  a  ;  the  part  between  the  lines  at  b  and  c  was  a  second- 
ary deposit.     (From  a  specimen  in  the  Buffalo  College  Museum.) 

much  more  frequently  the  consequence  is  the  deposition  about  the 
wound  of  secondary  dentine,  which  perhaps  will  entirely  inclose  and 
segregate  the  original  cause  of  irritation,  and  form  septa  across  the 
pulp  chamber.  With  the  continuous  growth  of  the  tooth  or  tusk 
this  is  carried  forward,  until,  perhaps  many  years  subsequently, 
when  the  animal  is  killed  and  its  tusk  falls  into  the  hands  of  the 
ivory  cutters,  the  original  bullet,  with  the  secondary  formation 
about  it,  is  found  in  the  solid  ivory,  perhaps  one  or  two  feet  from 
the  skull.      (See  Figs.  60  and  61.) 


SECONDARY  DENTINE,   PULP   NODULES,   AND   CALCIFICATIONS.       221 

Nature  sometimes  throws  out  a  layer  of  secondary  dentine  to 
protect  the  pulp  from  slowly  advancing  caries,  or  erosion.     The 

formative  cells  at  the  periphery  of  the  threatened  portion  of  the 
pulp  are  by  the  irritation  stimulated  to  increased  functional 
activity,  and  a  kind  of  hypertrophy  of  dentine  is  the  result.  Prac- 
titioners have  sometimes  seen  this  take  place  under  a  plastic  filling 
that  had  been  inserted  over  a  nearly  exposed  pulp.  In  the  course 
of  a  few  years  this  perhaps  became  sufihcient  support  for  a  solidly 
impacted  metal  filling.  This  is  the  result  hoped  for  in  all  instances 
of  ordinary  capping.  Fractured  teeth  have  been  known  to  be 
united  by  a  secondary  growth  of  dentine,  though  these  instances 
are  probably  few  in  number. 

The  formation  of  so-called  pulp  stones  and  secondary  dentine 
is  a  much  more  common  occurrence  than  is  usually  imagined.  The 
examinations  of  the  pulp  chambers  of  extracted  teeth  in  the  teach- 
ing df  operative  technics  in  some  of  the  colleges,  shows  that  a  con- 
siderable proportion  of  teeth  are  thus  affected.  The  late  Prof. 
A.  P.  South  wick,  of  Buffalo,  who  was  one  of  the  most  observant, 
and  successful  of  technic  teachers,  believed  that  from  sixty  to 
seventy  per  cent,  of  extracted  teeth  show  some  form  of  it,  but  as 
this  applies  chiefly  to  such  as  have  been  extracted  for  diseased  con- 
ditions, probably  it  would  not  hold  good  universally. 

The  formations  within  the  pulp  chamber  are  sometimes  the 
cause  of  considerable  local  irritation,  but  neither  the  objective  nor 
the  subjective  symptoms  of  these  conditions  are  sufficiently  distinc- 
tive to  afford  reliable  means  of  diagnosis.  When  they  are  of  rapid 
growth  the  pain  may  be  of  an  acute  character,  but  they  do  not 
under  ordinary  circumstances  induce  any  breaking  down  of  pulp 
tissue,  nor  do  they  bring  about  any  serious  complications.  Usually 
the  suffering  is  of  that  subacute  nature  that  is  hardest  to  locate. 
It  presents  no  special  distinguishing  characteristics,  and  a  diagnosis 
can  only  be  safely  made  through  exclusion.  When  it  is  certain  that 
the  pain  arises  from  nothing  else,  it  may  be  attributed  to  secondary 
formations.  It  might,  by  the  superficial  observer,  readily  be  mis- 
taken for  facial  neuralgia,  but  it  is  not,  like  that,  paroxysmal  or 
periodical.     Nor  is  it  so  acute  or  so  intense  in  its  nature. 

The  presence  of  pulp  stones  will  not  usually  be  suspected  until 
they  are  discovered  through  pulp  exposure.  Not  infrequently  they 
will  seriously  embarrass  the  dentist  in  his  efforts  at  pulp  devitali- 


222  ORAL    PATHOLOGY   AND   PRACTICE. 

zation  and  extirpation.  Sometimes  in  their  presence  it  is  with  the 
utmost  diffipulty  that  even  arsenous  acid  can  be  made  to  produce 
its  characteristic  effect.  Why  this  should  be  the  case  to  such  a 
marked  degree  it  is  impossible  to  say,  as  the  secondary  formation 
does  not  usually  make  an  entire  septum  in  the  pulp  chamber. 
That  it  may  completely  bar  the  proper  filling  of  the  roots  of  a 
tooth  is  more  conceivable,  for  the  growth  may  be  so  attached  to  the 
ordinary  dentinal  walls  as  to  make  its  removal  very  difficult.  It 
may  form  such  an  obstruction  in  a  root  canal  as  will  absolutely 
forbid  the  passage  of  an  instrument.  In  such  instances  the  Papain 
digester,  as  recommended  by  Professor  A.  W.  Harlan,  may  be  made 
tc  serve  a  specially  useful  purpose  in  removing  portions  of  the 
devitalized  dental  pulp  which  are  beyond  the  reach  of  instruments. 
In  the  past  there  has  been  no  resource  save  the  slow  and  uncertain 
process  of  sloughing,  which  implies  an  infected  root  canal. 

The  presence  of  secondary  formations,  then,  will  only  be 
positively  known  when  it  is  too  late  for  anything  but  removal,  when 
this  is  practicable.  If  they  are  floating  in  the  pulp  chamber  this 
will  not  be  a  difficult  matter.  But  if  they  are  attached  to  the 
dentinal  walls  it  may  be  impossible.  It  is  not  a  safe  practice  to 
attempt  to  drill  them  out,  nor  in  all  cases  would  this  materially 
assist  in  the  subsequent  treatment  and  filling  of  the  root.  The 
operative  dentist  will  be  obliged  to  take  them  out  by  enlarging  the 
opening  into  the  pulp  chamber  when  this  is  practicable,  or  to  use 
sufficient  time  thoroughly  to  sterilize  any  fragments  of  remaining 
pulp  tissue,  and  then  to  fill  as  best  he  can,  using  some  plastic 
material  for  the  pulp  chamber. 


CHAPTER   XLVIil. 
HYPERCEMENTOSIS. 


Hypercementosis  is  the  analogue  of  hyperostosis,  or  exostosis,  of 
bone.  Technically  it  is  a  tumor,  but  always  of  benign  growth.  It 
is  an  hypertrophy  of  the  cementum,  and  has  its  origin  in  some  form 
of  irritation  that  is  just  sufficient  to  stimulate  the  pericementum  to 
an  abnormal  activity.  (See  Fig.  63.)  It  may  be  local,  and, affect 
but  one  tooth,  or  the  irritation  and  stimulus  may  be  so  general  as  to 


HYPERCEMENTOSIS.  223 

induce  an  excessive  deposit  of  cementum  in  some  form  upon  all,  or 
nearly  all,  the  teeth  of  either  jaw.  (See  Fig.  64.)  It  may  even 
be  more  comprehensive  than  that,  and  involve  the  osseous  tissues. 
Instances  have  occurred  in  which  hypercementosis  and  hyperostosis 
existed  together,  with  not  only  enlargement  of  the  roots  of  all  the 

Fig.  63. 


Hypercementosis  of  the  Roots  of  a  Lower  Molar  showing  Stimulation 
OK  THE  Entire  Pericemental  Membrane. 

teeth,  but  of  the  whole  alveolar  process  of  the  bone  as  well.  Nodules 
of  exostosed  bone  may  sometimes  be  felt  along  the  alveolar  portions 
of  the  lower  jaw  especially,  and  these  are  apt  to  be  associated  with 
expansion  of  the  roots  of  the  teeth  from  hypercementosis.  (See 
Fig.  65.) 

Fig.  64. 


General  Pericemental  Hyperplasia.    Teeth  Successively  Lost  by  One  Patient. 

The  Two  on  the  Right  were  Fused  together  by  the  Hyperplastic  Cementum. 

(Practice  of  Dr.  William  Jarvie.) 

The  condition  is  not  one  that  presents  very  special  pathogno- 
monic symptoms.  Unless  it  is  accompanied  by  hyperostosis,  there 
will  be  no  external  indications  of  its  existence.  Nor  is  it  provoca- 
tive of  much  pain.  Hence  its  diagnosis  is  at  times  difficult,  or  even 
impossible.  There  may  be  a  feeling  of  pressure  and  general  un- 
easiness in  the  teeth  affected,  but  it  will  not  be  sufficient  to  furnish 
a  diagnostic  sign.     There  are  no  special  complications,  and  hence 


224 


ORAL    PATHOLOGY    AND    PRACTICE. 


the  condition  is  not  one  of  great  pathological  importance.  Its  chief 
import  to  the  practicing  dentist  lies  in  its  being  an  impediment  to 
extraction,!  and  when  that  is  imperative  may  make  it  necessary  to 
cut  through  the  investing  alveolar  process  before  the  tooth  can  be 
lifted  out.  This  will  only  be  called  for  at  the  cervical  constricted 
portion  above  the  expanded  part  of  the  root.  There  will  have 
been  a  resorption  of  the  investing  bone  sufficient  to  accommodate 
the  hypertrophy  itself,  and  the  cutting  through,  or  removal  of  a 
part  of  the  constricted  superficial  alveolar  process  is  but  a  simple 


Fig.  65. 


Nodular  HvptRCEMENTosis  with  Accompanying  Hyperostosis. 

a.  Osteophytes  upon  the  external  alveolar  surface;  b,  Irregular  cemental  growth,  involving 
both  buccal  roots ;  c,  Cementum  nodules.  The  teeth  were  so  bound  together  by  the  interlock- 
ing of  the  cemental  growths  that  all  three  unavoidably  came  away  together  with  the  exertion  of 
but  moderate  force,  causing  an  opening  into  the  antrum.     (Practice  of  Dr.  G.  C.  Daboll.) 

operation,  and  is  very  much  preferable  to  a  long  struggle  to  effect 
expansion  in  continued  efforts  to  extract  the  tooth,  with  the  liabihty 
to  its  accidental  fracture  under  the  forceps. 

Microscopical  sections  of  portions  of  hypertrophies  of  the  cemen- 
tum show  that  they  have  the  true  cemental  structure,  and  there  is 
no  special  line  of  demarkation  visible  between  the  new  and  the  old 
formation.  Pigmentation,  or  coloring,  is  not  uncommon,  its  most 
usual  form  being  a  deep  yellow  or  light  brown  tinge.  The  cemen- 
tum corpuscles  are  often  unusually  large,  so  that  the  nutrition  of 
the  hypertrophied  and  original  tissue  is  very  well  carried  oh,  for 
perhaps  obvious  reasons.     A  clinical  and  microscopical  study  of 


DISCOLORED   TEETH.  22  = 


the  pericementum  in  these  conditions  has  not  hitherto  been  made. 
When  this  is  undertaken  further  Hght  upon  this  interesting  subject 
will  without  doubt  be  afforded. 


CHAPTER  XLIX. 
DISCOLORED  TEETH. 


While  the  remedial  measures  for  the  relief  of  discolored  teeth 
belong  rather  to  operative  dentistry,  and  are  outside  the  scope  of 
this  work,  yet  a  little  may  be  said  concerning  the  cause  of  dis- 
coloration, which  may  be  due  either  partially  or  entirely  to  patho- 
logical conditions.  People  sometimes  present  themselves  to  the 
dentist  with  the  request  that  an  objectionable  color  of  the  whole  or 
parts  of  the  teeth  may  be  discharged,  when  it  is  plainly  evident  that 
it  is  congenital.  Some  people  have  yellow,  and  some  dark  teeth 
naturally,  and  no  skill  is  sufficient  to  alter  this  without  material 
injury.  The  leopard  cannot  change  his  spots,  nor  the  Ethiopian 
his  skin. 

But  there  are  pigmentary  deposits  upon  the  surface,  and  stain- 
ing which  penetrates  to  a  little  depth,  that  it  is  possible  to  remove. 
Of  these  the  most  common  is  the  so-called  "green  stain"  so  fre- 
qtiently  found  on  the  teeth  of  children,  and  the  analogous  brown  or 
reddish-brown  pigmentation  on  those  of  older  growth.  It  has  no 
special  pathologic  signification,  and  may  readily  be  removed  by 
tinct.  iodine  and  pulverized  pumice.  (See  Fig.  39.)  Dead  dentine, 
the  tubules  of  which  have  become  filled  with  pigmentary  matter, 
may  be  bleached  by  chemical  agents.  Usually  these  deposits,  either 
upon  or  within  the  substance  of  the  teeth,  are  of  a  yellow  or  dark 
color,  but  in  some  instances  the  teeth  are  turned  to  a  bright  blue, 
or  even  an  intense  green.  Workers  in  different  metals  may  have 
their  teeth  stained  by  minute  particles.  This  is  especially  the  case 
with  brass,  nickel,  and  copper  workers.  When  this  is  superficial 
it  may  be  readily  removed,  but  when  it  has  penetrated  the  substance 
of  the  tooth  it  presents  greater  obstacles. 

It  is  not  usually  the  case  that  a  tooth  containing  a  living  pulp 
is  affected  by  anything  beyond  mere  shallow  exterior  discoloration. 
There  may  be  congenitally  maculated  spots,  or  atrophied  regions 

16 


226  ORAL    PATHOLOGY    AND   PRACTICE. 

that  become  pigmented,  but  any  material  changes  of  color  are 
usually  associated  with  a  devitalization  of  the  affected  tissue.  As 
the  consequence  of  a  sharp  blow,  and  sometimes  too  protracted 
or  severe  dental  operations,  a  tooth  has  been  known  to  as- 
sume a  bright  pink  appearance.  This  is,  however,  the  result  of 
death  of  the  pulp.  While  the  red  blood  corpuscles  are  much  too 
large  to  enter  the  dentinal  tubules,  their  stroma  may  be  ruptured 
and  the  hemoglobin  may  penetrate  the  tubuli,  giving  the  red  tint. 
Subsequent  changes  in  this  substance  may  produce  a  gray  or  brown 
color,  which  finally  becomes  fixed  as  a  very  dark  or  blackish  tint  by 
the  action  of  iron  or  sulphur.  This  is  more  apt  to  be  the  case  in  man 
than  in  woman,  because  the  percentage  of  accidents  is  somewhat 
higher.  The  changes  are  analogous  to  those  that  take  place  when 
one  has  a  "black  eye,"  but  as  there  are  no  absorbents  to  take  up  the 
decomposed  blood,  it  remains  a  black  or  dark  color. 

The  dentinal  fibrillge  themselves  may,  instead  of  being  sloughed 
out,  remain,  and  after  desiccation  or  drying  undergo  slow  retro- 
gressive changes  that  leave  the  dentine  a  dirty  yellow  or  dark 
brown  color.  Foreign  matter  may  enter  the  tubuli,  and  there 
slowly  become  carbonized,  and  thus  form  another  cause  of  dis- 
coloration. Substances  used  in  filling  may  impart  a  stain  to  the 
idevitalized  dentine.  Oxidation,  or  other  chemical  changes  going 
lOn  in  metals  used  for  posts  to  assist  in  the  retention  of  fillings,  may 
induce  pigmentation  more  brilliant  than  ornamental.  Thus  a  piece 
of  copper  has  been  known  to  impart  to  a  whole  crown  a  beautiful 
^reen  color,  while  nickel  has  given  a  color  approaching  turquoise 
blue. 

The  most  effective  means  for  the  discharge  of  the  yellow  or 
dark  colors  is  by  the  use  of  chlorine  gas.  Oxygen  is  really  the 
active  agent,  but  the  most  convenient  way  to  generate  it  is  by  the 
use  of  some  preparation  that  will  liberate  chlorine  gas,  and  this,  in 
the  presence  of  water,  unites  with  the  hydrogen  and  sets  free 
■oxygen,  which  accomplishes  the  work.  Peroxide  of  hydrogen  and 
pyrozone,  both  of  which  loosely  hold  in  solution  an  extra  volume 
■of  oxygen,  are  also  used  for  the  purpose.  It  is  sometimes  neces- 
sary to  repeat  the  bleaching  a  number  of  times,  for  the  discolora- 
tion is  likely  to  return  until  all  the  colorization  changes  have  ceased. 

As  it  is  difficult  to  force  the  bleaching  agent  very  far  into  the 
■dentinal  tubuli,  it  is  usual  to  cut  out  all  the  discolored  tissue  that  it 


CONGExVITAL    IMlMiRFECTIONS    OF    ENAMEL. 


227 


is  possible  to  spare  before  commencing  the  process.  Tlie  bleach- 
ing interferes  with  the  integrity  of  the  tissue,  and  weakens  the 
tooth.  Large  contour  restorations,  after  this  process,  are  therefore 
Hkely  to  fail;  this  tact,  with  the  liab'lity  to  recurrence  o^  the  pig- 
mentation, has  made  crowning  rather  to  be  preferred  in  many  cases. 


CHAPTER    L. 

CONGENITAL    IMPERFECTIONS   OF   ENAMEL. 

"While  enamel  is  organic  in  the  sense  that  it  is  the  product  of 
function  or  growth,  its  proportion  of  living  matter  is  so  small  that 
natural  reparative  processes  or  spontaneous  degenerative  changes 
are  practically  impossible.  Its  proximate  principles  are  inorganic, 
though  of  organic  origin.  In  the  eruption  of  the  tooth  all  connec- 
tion between  the  enamel  and  its  formative  organ  is  necessarily  de- 

FiG.  66. 


Total  Lack  of  Development  of  the  Crowns  of  the  Teeth.    Cast  of  the   Upper 

Jaw  of  a  Young  Man.    The  Peculiarity  is  the  Result  of  Inheritance. 

(From  a  case  in  practice.) 

stroyed.  Its  relations  are  such  that  there  can  be  no  nutritive  circu- 
lation, and  hence  practically  it  can  undergo  no  changes  except  such 
as  are  retrogressive  in  their  nature.  And  yet,  because  of  its  con- 
nection with  vital  tissue,  the  proportion  of  living  matter  in  its 
composition,  which  though  small,  is  constant,  as  well  as  the  fact  of 
its  genetic  origin  from  bone,  of  which  it  is  a  modification,  its  con- 
sideration as  inorgfanic  is  forbidden. 


228 


ORAL    PATHOLOGY    AND    PRACTICE. 


These  facts  indicate  that  enamel  degenerations  are  not,  strictly 
speaking,  pathological,  and  that  their  treatment  must  be  from  a 
chemical  and  mechanical  standpoint,  rather  than  from  one  which  is 
medicinal  or  vital.  By  this  it  is  not  meant  that  therapeutic  agents 
are  never  to  be  employed,  or  that  special  remedies  may  not  some- 
times be  useful.  But  such  agents  should  either  be  directed  toward 
the  stimulation  of  constitutional  functional  activity,  or  the  neutral- 
ization of  deleterious  products,  the  result  of  some  vital  derange- 
ment. Thus  general  alterative  treatment  may  change  the  char- 
acter of  environing  secretions,  or  local  applications  may  make  them 

innocuous. 

Fig.  67. 


Cast  of  the  Lower  Jaw  of  the  Case  Represented  in  Fig.  66.  A  Very  Thin  Edge 
OF  Enamel  Appeared  at  the  Cervical  Margins  of  aFewof  the  Teeth.  There 
WAS  None  upon  the  Occlusal  Surfaces,  the  Dentine  being  Exposed  and  of  a 
Light  Amber  Color. 


The  imperfections  of  enamel  may  be  divided  into  two  classes: 
those  which  are  formative  or  natural,  and  those  which  are  deriva- 
tive or  acquired.  The  first  of  these  will  consist  of  the  structural 
imperfections  produced  by  aberrant  conditions  during  the  process 
of  development,  while  the  latter  will  be  the  result  of  subsequent 
abnormal  and  unnatural  environments,  or  the  subjection  of  the 
teeth  to  exceptional  conditions.  The  first  named  will  be  apparent 
when  the  teeth  are  erupted,  while  the  last  will  only  be  observed  as  a 
natural  effect  of  the  anomalous  surrounding  circumstances. 

It  has  already  been  asserted  that  enamel  is  a  modification  of 
bone,  composed  of  precisely  the  same  elements,  though  in  varied 


CONGExVITAL    IMPERFECTIONS    OF    ENAMEL. 


229 


•proportions  and  modified  structure.  (See  Chapter  XXII. ).  Its 
growth  is  a  physiological  process,  and  is  subject  to  natural  law. 
Pathological  derangements  may,  however,  induce  such  deflections 
of  nutritive  currents,  or  such  structural  imperfections  in  the  forma- 
tive enamel  matrix,  as  may  result  in  defects  or  faults,  or  even 
entire  absence  of  enamel.  It  is  readily  conceivable  that  any  func- 
tional disturbance  of  a  grave  character  might  bring  this  about,  but 
as  the  tissue  is  of  epiblastic  origin,  any  disease  which  materially 
involves  epithelial  structure,  it  might  easily  be  imagined,  would, 
during  the  formative  period  of  enamel,  leave  upon  it  an  indelible 

Fig.  68. 


Figs.  66  and  67  as  They  Appeared  in  Occlusion.    The  Condition  was  that  which 

■    WAS   N.ATUR.-VL   IN    THIS   CaSE   AND    XOT   THE    EFFECT   OF   WEAR. 


mark.  Hence  to  the  eruptive  diseases  of  childhood  have  been 
ascribed,  correctly  or  incorrectly,  very  many  of  the  imperfections 
which  are  found  in  enamel  when  the  tooth  is  erupted.  That  this  is 
the  sole  cause  the  many  varying  phenomena  would  make  very  im- 
probable, to  say  the  least. 

It  is  sometimes  the  case  that  no  crown  whatever  is  developed, 
and  instances  have  been  known  in  which  all  of  the  permanent  teeth 
were  practically  crownless,  although  the  roots  were  fully  grown  and 
of  the  ordinary  size,  and  the  alveolar  process  was  of  the  usual  pro- 
portions. Such  a  case  in  the  practice  of  the  author  is  represented 
in   Figs.  66,  67,  and  68.     The  peculiarity  in  this  instance  was 


230  ORAL    PATHOLOGY    AND    PRACTICE. 

hereditary,  inclining  to  follow  the  law  of  atavism,  and,  so  far  as  the 
history  could  be  traced,  appearing  usually  in  not  more  than  one 
individual  in  any  generation.  "  The  cementum  and  dentine  of  the 
roots  were  normal,  while  the  enamel  was  either  wholly  lacking  or 
existed  but  as  a  friable  edge  at  the  cervix  of  a  very  few  of  the  teeth. 

In  this  instance,  no  enamel  organ  could  have  developed,  or  at 
the  best  it  must  have  been  rudimentary.  The  results  could  not 
have  been  produced  by  any  eruptive  disease,  nor  any  sudden 
constitutional  crisis  the  result  of  nutritive  changes.  The  incep- 
tion of  the  morbid  anatomical  condition  must  have  been  pre- 
natal, and  so  the  whole  was  congenital.  As  in  cleft  palate,  there 
must  have  been  deficiency  in  formation,  and  the  plastic  organ 
which  should  have  been  the  genetic  source  of  enamel  growth 
was  either  functionless  or  practically  wanting.  The  absence  of  an 
enamel  organ  would  change  the  whole  character  of  the  dental 
follicle,  and  the  dentinal  papilla  would  be  functionless,  so-  far 
as  the  development  of  that  part  of  the  dentine  which  is  in  relation 
with  the  enamel  is  co-ncerned.  But  as  that  tissue  is  mesoblastic 
in  its  origin,  when  the  cementum  was  organized  through  the 
growth  of  pericementum  the  function  of  the  dentinal  papilla 
below  the  crown  would  not  be  materially  interfered  with  and 
the  root  would  present  a  natural  appearance. 

That  which  was  general  in  the  instance  cited,  might  in  other 
cases  be  local  or  partial,  and  this  would  account  for  the  total  or 
limited  loss  of  enamel  in  individual  teeth.  Such  limitation  of  the 
evolution  of  the  enamel  organ,  or  imperfections  in  it,  would  be 
most  likely  to  appear  along  its  internal  epithelial  border,  or 
that  which  initiates  the  process  of  enamel  formation,  and  hence 
it  is  that  the  incisive  portions  are  those  which  are  most  imper- 
fect, while  that  which  is  later  organized  may  be  quite  normal  in 
structure,  a  condition  that  is  commonly  observed  in  aberrations 
of  the  six  anterior  teeth  and  the  first  permanent  molar.  (See 
Fig.  69.)  The  influences  may  affect  the  whole  enamel,  though 
in  a  less  degree  in  the  later  stages  of  formation.  (See  Fig.  70 
and  Fig.  71.) 

That  the  exanthematous  diseases  may  exert  a  grave  influence 
upon  enamel  formation  few  will  dispute.  They  must  affect  all 
epithelial  tissues,  and  accordingly,  aside  from  or  as  a  part  of  the 
general  degeneration  that  accompanies  them,  there  may  be  observed 


CONGENITAL   IMPERFECTIONS   OF    ENAMEL. 


231 


a  falling  of  the  hair,  with  the  appearance  of  atrophied  spots,  and 
in  some  cases  furrows  in  the  nails,  bearing  some  analogy  to  those  in 
the  teeth.  It  would  not,  however,  be  anticipated  that  they  would 
present   precisely   the    same   phenomena   with   those   which   are 

Fig.  70. 


Furrowed  Enamkl,  with  Malformations 

OF  THK  Crown  of  thk  Tooth. 

(Tomes.) 


Fig 


Entiri-;  .\bsk.nce  of  the  Enamkl  fru.m 

iHAT  Part  of  the  Crown  that  is 

First    Formed.    That    Later 

Developed  is  Perfect. 


Furrowed  Enamel,  consisting  of  Alternate  Grooves  and  Ridges  of  More 
Perfect  Tissue.     (Tomes.) 


Fig.  ^2. 


Fig.  -ji. 


IiMPERFFCT     ESAMI  r  ,     SHOWING      I  WO      DiS 

tinct  Series  of  Pits,  with  Perfect 

Enamel  between  them. 
(From  American  S>'Stem  of  Dentistry. ) 


Irregular  Pits  upon  the  Crowns  of- 
Teeth  Ascribed  to  Eruptive  or 

Exanthe.matous  Diseases. 


congenital  in  their  origin,  and  so  the  marks  upon  enamel  pro- 
duced by  the  eruptive  disorders  through  which  the  child  may 
have  passed  during  the  period  of  calcification  present  indications 
of  the   interruption  of  nutrition,   rather  than  entire  absence  of 


232 


ORAL    PATHOLOGY   AND    PRACTICE. 


any  formative  enamel  organ.  They  are  confined  to  the  enamel 
itself,  and  not  at  all,  or  but  in  a  slight  degree,  afifect  the  dentine 
beneath.  They  may  exist  as  a  kind  of  single  pitted  furrow  across 
the  face  of  the  tooth,  or  there  may  be  more  than  one  such,  show- 
ing successive  attacks.  (See  Fig.  72.)  Not  infrequently  they 
may  appear  as  shallow,  isolated  indentations  in  the  enamel,  giv- 
ing it  a  rough,  uneven  appearance,  and  they  bear  some  analogy 
to  the  cutaneous  pits  produced  by  smallpox.    (See  Fig.  73.) 

Fig.  74. 


Casts  of  the  Edentulous  Jaws  of  a  Man  of  Forty-five  Years  who  Never  had 
EITHER  Deciduous  or  Permanent  Teeth.  In  Addition  He  was  Without  Hair 
on  Either  Head  or  Body,  was  Lacking  in  the  Senses  of  Taste  and  Smell,  and 
was  Without  Any  Perspiratory  System. 

As  the  degenerations  considered  in  this  chapter  are  either 
pre-natal  in  their  origin,  or  are  dependent  upon  general  consti- 
tutional conditions  which  produce  their  characteristic  effects  be- 
fore the  teeth  are  erupted,  and  hence  in  neither  case  can  be 
diagnosed  or  anticipated  until  they  shall  have  made  their  appear- 
ance, when  it  is  too  late  for  the  adoption  of  any  prophylactic 
measures,  no  course  of  treatment,  aside  from  mechanical  meas- 
ures, can  be  recommended.  When  the  crowns  are  entirely 
absent,  artificial  ones  may  be  engrafted,  and  when  there  are 
imperfections  of  enamel  the  roughness  may,  to  a  certain  extent, 
be  removed  by  the  file  or  a  corundum  stone,  and  afterward  care- 
fully polished,  or  the  pits  may  be  filled  by  the  use  of  gold  or 
porcelain  inlays. 


ACQUIRED    OR   ACCIDENTAL    IMPERFECTiOXS    OF    ENAMEL.       233 


CHAPTER    LI. 

ACQUIRED  OR  ACCIDENTAL  IMPERFECTIONS  OF  ENAMEL. 

The  abrasions  or  erosions  of  enamel  which  appear  subsequently 
to  the  eruption  of  the  teeth  must  of  necessity  have  a  widely  different 
origin  from  the  imperfections  that  are  formative  or  congenital. 

As  the  proportion  of  living"  matter  in  the  constituent  elements  of 
enamel  is  proportionalh'  so  small,  and  as  there  can  be  no  nutritive 
currents  and  consequent  metabolic  changes  in  structure  because 
of  the  destruction  of  the  organ  which  afforded  nourishment 
during  growth,  any  modifications  or  degenerations  of  that  tissue 
after  it  is  once  formed  must  be  the  result  of  local  causes  and  due 

Fig.  75. 


«  i  i 


ist  year.  3d  year.    6th  year.     7th  year.    8th  year,     gth  year.     loth  year,     nth  year. 
Development  of  the  Superior  Central  Incisors.     (Broomell.) 


to  environing  conditions.  There  can  be  no  reconstruction  of 
that  which  has  once  been  lost,  nor  can  there  practically  be  natural 
recuperation  from  the  effects  of  diseased  conditions.  All  changes 
must  of  necessity  be,  to  all  intents  and  purposes,  retrogressive  in 
their  nature  and  the  result  of  extraneous  causes. 

Aside  from  caries  and  the  results  of  accident,  the  degenerations 
of  formed  enamel  must  result  from  either  attrition  or  chemical  solu- 
tion. It  is  not  meant  to  be  asserted  that  theoretically  there  may  not 
be  structural  changes,  for  these  naturally  inhere  to  all  organic 
bodies,  but  practically  they  must  be  so  infinitesimal  in  enamel 
that  they  cannot  be  reckoned  as  a  factor  worth  mention  in  con- 
sidering  the   present    subject.      That    the    tissue    does    undergo 


234  ORAL    PATHOLOGY   AND   PRACTICE. 

certain  superficial  modifications,  the  clinical  experience  of  most 
experienced  dentists  will  establish.  There  are  times  when  it 
seems  specially  subject  to  wear  and  attrition.  But  as  these 
conditions  cannot  be  the  result  of  functional  action,  they  must 
be  accidental  and  due  to  some  special  state  of  the  oral  secretions 
and  fluids. 

That  which  has  been  denominated  "mechanical  abrasion," 
the  ordinary  wear  of  teeth,  presents  no  unexplainable  phenomena. 
Certain  kinds  of  food  abrade  the  grinding-  surfaces  of  the  teeth 
very  fast.  Those  of  the  early  Indians  of  the  Southwest  were, 
in  adult  life,  usually  worn  down  nearly  to  the  gums  by  the  silicious 
covering  of  the  corn  which  formed  the  principal  article  of  their 
diet.  Among  our  own  people,  when  mastication  must  be  ex- 
clusively done  upon  the  anterior  teeth  because  of  loss  of  the 
molars,  in  time  the  upper  incisors  are  apt  to  become  so  worn 
and  channeled  as  to  present  the  appearance  of,  and  by  the  laity 
b^  mistaken  for,  "double  teeth."  The  tooth-brush  may  be  re- 
sponsible for  some  of  that  upon  the  labial  aspects,  but  aside 
from  the  evident  results  of  attrition,  there  appear  occasional 
furrows  and  concavities  that  are  not  congenital  and  that  cannot 
be  the  consequence  of  any  usual  cause.  Sometimes  these  occur  as 
deep  pits  in  the*  occluding  surface  of  a  molar,  without  a  corre- 
sponding protuberance  on  its  antagonist.  The  channels  may  be 
between  teeth,  where  no  brush  could  reach  them.  They  are  even 
found  in  the  teeth  of  wild  and  domestic  animals,  the  brush  as  a 
necessary  cause  being  thus  eliminated.  Cases  have  been  known  in 
which  upper  incisors,  for  instance,  have  the  appearance  of  being 
regularly  and  evenly  chamfered  from  the  cervical  portion  to  the 
point,  as  if  done  with  a  flat  file.  In  other  instances  there  is  a  suc- 
cession of  erosive  channels  or  excavations,  symmetrical  and 
usually  following  the  line  of  the  gingival  border.  (See  Fig.  y6.) 
One  peculiarity  of  this  condition  is  that  the  surface  left  is  smooth, 
and  in  some  instances  apparently  polished. 

Very  frequently  the  excavations  are  near  the  margin  of  the 
gum,  and  their  edges  may  be  too  sharp  and  well  defined  to  be 
caused  by  any  common  form  of  attrition,  in  some  instances  pre- 
senting a  distinct  undercut.  They  may  be  confined  to  a  single 
one,  or  may  affect  a  series  of  teeth.  Usually  they  are  found  only 
upon  the  buccal  or  labial  aspect,  occasionally  on  the  proximate, 


ACQUIRED   OR    ACCIDENTAL    IMPERFECTIONS    OF    ENAMEL.       235 

and  very  rarely  upon  the  lingual  surfaces.  They  do  not  seem  to 
be  necessarily  connected  with  any  special  diathesis,  for  they  are 
found  in  the  teeth  of  people  who  show  no  indications  of  gout,, 
rheumatism,  or  any  of  the  diseases  to  which  they  have  by  some 
been  attributed.  No  explanation  has  ever  yet  been  presented 
that  will  account  for  all  cases  of  abrasion.  Chemical  solution  by 
mineral  acids  is  not  suiBcient,  because  any  acid  sufficient  to 
account  for  the  erosion  of  the  surfaces  of  incisors  must 
manifest  itself  in  other  ways;  besides,  this  at  times 
occurs  when  the  reaction  of  the  oral  secretions  is 
n9t  strongly  acid.  It  has  been  attributed  to  electro-chemical  cur- 
rents which  produce  electrolysis.  The  improbability — nay,  more,, 
the  absolute  impossibility — of  the  existence  of  such  currents  in  the 
mouth  seems  too  apparent  to  need  demonstration.     There  is  no 


Fig.  ^d. 


Erosion  of  the  Teeth.     (Darby,  from  Burchard.) 

question  that  electrical  currents  are  constantly  being  formed  by  the 
incessant  chemical  action  and  the  different  molecular  changes  that 
never  cease  in  the  oral  cavity,  but  it  must  also  be  as  true  that  they 
are  as  perpetually  and  as  instantly  dissipated.  There  can  be  nO' 
closed  circuits,  nor  any  such  thing  as  accumulation;  and  hence, 
while  theoretically  they  may  be  present,  practically  they  must  as 
inevitably  be  powerless  for  either  good  or  evil,  vanishing  on  the 
instant  of  their  birth. 

It  seems  to  be  true  that  while  the  acid  reaction  in  some 
instances  of  erosion  may  be  weak,  so  far  as  observation  goes  it 
always  exists.  It  is  well  known  that  organic  acids  in  their  nascent 
state  are  most  active.  While,  therefore,  through  fermentation  or 
in  a  degenerative  state  of  the  mucous  follicles  an  acid  may  by 
combination  be  formed  in  a  circumscribed  locality,  and  there,  on  the 
spot  of  its  birth,  have  sufficient  force  to  attack  tooth  substance,  as 
soon  as  it  becomes  diluted  and  its  affinities  are  partially  satisfied 
it  might  give  but  a  weak  reaction  when  tested.     In  this  fact  may  be 


^236  ORAL    PATHOLOGY    AND    PRACTICE. 

found  a  partial  answer  to  some  phenomena.  But  fermentative 
acids  would  not  probably  be  formed  upon  the  most  prominent 
labial  surfaces  of  incisors  for  instance,  where  they  are  most  free 
from  any  foreign  fermentable  substance,  and  where  they  are 
constantly  washed  by  the  saliva  and  kept  clean  by  the  friction  of 
the  lips. 

The  excavations  or  cavities  formed  by  erosion  bear  some 
analogy  to  those  in  certain  instances  of  caries.  The  loss  of  tooth 
substance  is  as  positive,  its  attacks  may  be  seen  in  the  same 
localities  and  the  form  of  the  excavation  is  very  like  that  in  some 
kinds  of  superficial  decay.  (See  Fig.  yy^  But  there  the  resem- 
blance ceases.    Both  may  be  the  result  directly  of  the  decalcifying 


Fig.  T/. 


Erosion  of  the  Teeth  on  the  Labio-Gingival  Areas.     (Darby,  from  Burchard.) 


.action  of  some  acid,  but  in  caries  there  is  infection  and  the  action 
of  both  fermentative  and  putrefactive  organisms,  while  no  septic 
condition  accompanies  erosion.  In  caries  there  is  the  formation 
of  minute  caverns  in  the  dentine,  with  subsequent  crumbling  of 
the  friable  tissue,  leaving  a  rough  cragged  surface,  while  in 
•erosion  the  bottom  of  the  excavation  is  smooth,  or  even  polished. 
•(See  Fig.  78.)  Miller  asserts  that  even  when  calcining  has  re- 
moved all  the  organic  material  from  the  tooth,  the  eroded  surface 
still  retains  this  polished  appearance,  indicating  that  essentially 
the  process  is  very  distinct  from  the  minute  excavations  of  caries. 
A  degenerative,  acid  condition  of  the  secretions  of  the  special- 
ized mucous  glands  at  the  gingival  margins  might,  and  probably 
"does,  account  for  some  of  the  peculiar  erosion  that  exists  in  such 
localities,  but  it  offers  no  explanation  for  that  upon  the  occluding 
or  incisive  edges  of  the  teeth.  Vital  depression,  an  atonic  condi- 
tion that  offers  a  decreased  resistance  to  degenerative  changes,  are 


ACQUIRED    OR    ACCIDENTAL    IMPERFECTIONS    OF    ENAMEL.       2-};j 

terms  too  vague  and  indefinite  to  be  accepted  as  elucidations  of 
such  a  condition  as  abrasion. 

We  are  simply  reduced  to  the  alternative  of  accepting  explana- 
tions that  do  not  explain,  or  frankly  admitting  that  there  is  much ' 
in  this  condition  which  with  our  present  knowledge  is  not  com- 
prehensible. There  are  factors  at  work  which  we  probably  know 
not.  That  it  is  an  external  agent  of  some  kind  is  proven  by  the 
fact  that  a  protective  filling,  when  well  inserted,  always  screens 
the  tissue  that  it  covers.  The  wasting  process  may  go  on  all 
about  the  filling,  but  it  ceases  beneath  it. 


Fig.  78. 


Erosion  of  the  Enamel  SuRFAi^hb  ut    ihb   ihETH  Extending  into  the  Dentine. 
by  Profile  of  the  depth  of  the  erosion  in  the  left  upper  and  lower  central  incisors.     (Black,, 
from  Burchard.) 

In   the    absence    of    definite    knowledge    of    the    etiology   of 
erosion,  any  positive  prophylactic  treatment  cannot  be  laid  down. 

Filling  prevents  penetration,  but  it  does  not  in  all  cases 
debar  extension.  It  forms  the  only  effective  operative  treat- 
ment that  can  be  pursued,  for  usually  there  is  no  polishing  or 
cleaning  to  be  done.  If  there  is  a  distinctly  acid  reaction  of  the 
fluids  of  the  mouth  it  shows  that  assimilation  and  nutrition  are 
interfered  with,  and  relief  may  be  found  in  alterative  remedies,  and 
in  change  of  climate,  out-of-door  exercise,  or  perhaps  the  use  of 
tonics.  Lime-water  may  be  used  as  a  gargle,  and  at  night  a 
spoonful  of  Phillips's  milk  of  magnesia  may  be  rinsed  about  upon 
the  teeth  and  left  there  until  morning,  or  until  it  is  slowly  dissolved 
off.  Moderate  friction  of  the  gums  with  the  brush,  and  massage 
with  the  ball  of  the  finger,  are  always  stimulating  and  useful. 


238  ORAL   PATHOLOGY   AND    PRACTICE. 

CHAPTER  LII. 
REPLANTATION;  TRANSPLANTATION;  IMPLANTATION. 

Replantation  ^nd  transplantation  are  the  insertion  of  an 
extracted  tooth  in  a  natural,  and  implantation  in  an  artificial 
alveolar  socket.  Replantation  is  the  replacing  of  a  tooth  in  the 
same  place  from  which  it  was,  either  accidentally  or  purposely, 
extracted.  Transplantation  is  the  removal  of  a  tooth  from  one 
mouth  to  another.  This  was  originally  performed  by  placing  the 
'donor  and  receiver  in  the  same  room,  and  then  extracting  a  dis- 
■eased  or  decayed  tooth  from  the  latter  and  immediately  substitut- 
ing it  by  one  extracted  from  the  former,  without  any  special  prep- 
aration. But  the  unfortunate  inoculation  of  a  communicable  dis- 
ease in  some  instances  of  transplantation  brought  the  operation 
into  disfavor.  With  the  advance  in  pathological  knowledge,  more 
especially  that  of  bacteriology,  better  methods  for  its  performance 
have  been  devised. 

Replantation  is  called  for  in  instances  in  which  teeth  have 
l)een  forced  from  their  investment  by  accident,  or  extracted  by 
mistake,  or  taken  out  in  special  conditions.  There  is  no  bone 
that  heals  so  readily  as  does  the  alveolar  process  of  the 
maxilla,  and  even  though  there  are  compound  fractures  the  parts 
readily  unite  if  nutrition  can  be  kept  up  in  them.  A  tooth  may  be 
knocked  out  by  accident,  and  may  even  remain  out  for  a  consider- 
able number  of  hours,  and  if  it  is  simply  washed  off  and  placed 
back  in  the  socket  it  may  readily  unite  again.  But  if  no  antiseptic 
precautions  are  taken  the  probabilities  are  that  an  alveolar  abscess 
will  be  the  consequence. 

It  is  sometimes  good  practice  to  extract  a  tooth  with  the  expec- 
tation of  replacing  it.  A  broach  may  have  been  forced  through 
the  foraminal  opening,  which  it  has  been  found  impossible  to  re- 
move. In  a  number  of  such  instances  that  have  presented  them- 
selves to  the  author,  he  has  promptly  extracted,  removed  the 
broach,  given  proper  treatment,  and  reinserted  the  tooth,  always, 
so  far  as  he  knows,  with  success.  Cases  of  persistent  and  un- 
accountable pain  that  was  located  in  the  tooth  have  been  so 
remedied.  In  instances  of  incurable  alveolar  abscess,  perhaps  due 
to  secondarily  infected  pockets,  or  to  foci  of  infection  along  the 


REPLANTATION,    TRANSPLANTATION,    IMPLANTATION. 


239 


side  of  the  root  where  there  were  nutritive  canals  penetrating  to 
the  pulp  through  the  dentine,  or  in  which  the  inflammation  was  of 
that  low,  indolent,  subacute  nature  in  which  neither  resolution  nor 
active  suppuration  could  by  any  usual  means  be  brought  about, 
the  author  has  frequently  extracted  the  tooth,  and  after  proper 
treatment  and  preparation  replaced  it.     Sometimes  the  mere  trau- 

FiG.  79. 


PliNETRATION    OF    COCCUS    FORMS    INTO    THE   TUBULES    OF   A    REPLANTED    TOOTH,    SHOWING 
THAT  THE   PROCESS   OF  DECAY   DOES  NOT  MATERIALLY   DIFFER    FROM  ORDINARY  CARIES. 

(Miller.    Compare  with  Fig.  19.) 

matism  of  the  extraction  was  sufficient  to  induce  an  active,  acute 
inflammatory  stage,  in  place  of  the  sluggish  one.  The  possible 
contingencies  are  such,  however,  that  this  method  of  treatment 
is  only  recommended  as  a  last  resort  when  all  other  means  of 
relief  shall  have  failed. 

In  all  cases  of  plantation  the  most  careful  antiseptic  measures 
must  be  employed.     When  the  tooth  is  extracted,  or  as  soon  as 


240 


ORAL    PATHOLOGY    AND    PRACTICE. 


possible  after  its  violent  removal  by  accident,  it  should  be  placed 
in  a  warm  bichloride  of  mercury  solution  for  sterilization.  It 
should  be  handled  with  a  clean  napkin,  and  in  any  subsequent 
manipulation  should  be  frequently  returned  to  the  sterilizing 
solution,  which  may  be  kept  warm  by  placing  the  vessel  containing 
it  in  a  larger  one  holding  warm  water.  The  pulp  chamber  should 
be  drilled  open,  and  its  contents,  with  those  of  the  root  canals,  care- 
fully removed.  After  sterilization  and  drying  they  should  be 
thoroughly  filled,  any  openings,  foraminal  or  through  the  body  of 

Fig.  8o. 


Invasion  of  Rod  and  Thread  Forms  in  Replanted  Tooth. 
At  a  is  shown  the  well-known  "pipe-stem"  appearance.     (Miller.) 

the  root,  being  especially  looked  to.  The  apex  must  be  made 
smooth,  and  if  the  tooth  ends  in  a  sharp  point  it  is  well  to  cut  this 
off,  carefully  polishing  the  exposed  extremity.  If  the  perice- 
mentum which  comes  away  with  the  tooth  appears  red  and  con- 
gested, it  should  be  removed  without  any  injury  to  the  tooth  itself. 
Placing  the  prepared  tooth  in  the  sterilizing  solution,  atten- 
tion should  now  be  directed  to  the  socket.  This  must  be 
thoroughly  washed  out  by  syringing  with  an  antiseptic  solution, 
either  of  the  mercuric  chlorid  i  :  2000,  or  some  other  effective 
one.   If  pus  is  present,  a  disinfectant  like  peroxide  of  hydrogen  or 


REPLANTATION,    TRANSPLANTATION,    IMPLANTATION.  24I 

pyrozone  should  first  be  used.  All  these  should  be  employed  at 
blood  temperature,  or  about  100°  F.  If  there  is  any  specially 
septic  condition  the  alveolar  socket  should  be  minutely  examined 
with  a  probe,  to  determine  the  existence  of  secondary  pockets, 
which  should  be  thoroughly  sterilized. 

If  it  is  a  case  of  transplantation,  the  tooth  should  now  be  tried 
in  the  socket,  when  if  necessary  the  latter  may  be  deepened  or 
enlarged.  No  fear  of  any  specially  threatening  consequences  need 
be  entertained,  because  the  formation  of  new  bone  is  probable  and 
desirable. 

When  everything  is  ready  the  tooth  should  be  taken  from  the 
sterilizing  solution,  and  quickly  and  firmly  carried  to  place.  A 
little  subsequent  pain  is  to  be  expected,  because  of  the  presence  of 
fluids  in  the  socket;  these  will  be  gradually  absorbed  into  the 
tissues.  Care  must  be  taken  that  the  tooth  shall  not,  for  a  few 
days,  occlude  with  any  antagonist,  and  thus  keep  up  an  irritation. 
It  must  be  held  firmly  immovable  by  some  specially  devised 
apparatus,  or  by  the  use  of  a  ligature  woven  about  the  planted  tooth 
and  a  few  of  the  adjoining  teeth. 

It  is  surprising  how  well  the  ligature,  when  skillfully  adjusted, 
will  hold  a  tooth.  No  surgeon  would  attempt  to  reduce  a  fracture 
and  then  neglect  the  adjustment  of  a  splint  to  hold  everything 
immovable.  The  ligature  is  frequently  the  best  splint  that  can  be 
employed  for  loose  teeth.  Kowarski's  paste,  made  of  powdered 
celluloid  and  acetone,  will  hold  the  ligatures  in  position  and  form 
a  very  eiificient  and  lasting  aid  in  the  work. 

The  only  subsequent  treatment  necessary  will  usually  be  to  see 
that  all  remains  aseptic.  If  necessary,  careful  irrigation  with  a 
sterilizing  solution  should  be  kept  up  until  new  tissue  has  begun 
to  form.  If  there  is  the  least  sign  of  infection,  or  of  breaking 
down,  it  is  usually  better  to  remove  the  tooth,  search  for  any 
irritants,  more  carefully  sterilize,  and  insert  it  again. 

Implantation  has  become  an  accepted  method  of  practice  with 
many  oral  surgeons.  It  had  been  successfully  performed,  but  public 
attention  was  never  specially  called  to  it  until  Dr.  W.  J.  Younger 
repeatedly  demonstrated  its  entire  practicability.  The  opera- 
tion consists  in  the  forming  of  an  artificial  socket  in  the 
alveolar  process,  and  the  insertion  into  it  of  a  tooth  previously 
extracted.     Nor  is  it  essential,  although  it  is  advisable,  that  the 

17 


242 


ORAL    PATHOLOGY   AND   PRACTICE. 


implanted  tooth  shall  have  been  recently  extracted.  Successful 
operations  have  been  made  Avith  teeth  that  have  been  lying  about 
the  office  for  years.  A  very  superficial  comprehension  of  the  con- 
ditions involved  will,  however,  convince  any  one  that  such  an 
operation  will  give  very  much  less  promise  of  permanence  than 
when  a  tooth  not  full  of  cracks  and  checks  is  selected.  It  does 
not  need  much  physiological  or  pathological  knowledge  to  demon- 

FiG.  8i. 


Longitudinal  Section  of  Decayed  Dentine  from  a  Replanted  Tooth,  showing  the 

Distended  Tubules. 
a,  Liquefaction  caverns.    6,  Rents  due  to  the  advanced  stage  of  decomposition  of  the  den- 
tine.    (Miller.) 

strate  that,  other  things  being  equal,  the  better  and  fresher  the 
tooth  to  be  implanted  the  greater  the  chances  for  lasting  success. 

The  first  thing,  when  implantation  is  contemplated,  is  the 
selection  of  a  tooth.  This  should  be  done  with  an  eye  to  tempera- 
ment, size,  and  form.  The  proportion  of  the  length  and  thickness 
of  the  root  to  the  depth  and  breadth  of  the  alveolar  process  should 
be  observed,  so  that  proper  adjustment  may  be  possible.  The 
directions  given  for  the  proper  preparation  of  a  tooth  for  replanta- 
tion are  applicable  to  cases  of  implantation,  and  need  not  be 
repeated. 

The  formation  of  the  artificial  socket  in  the  alveolar  process 
is  done  by  laying  back  the  gum  and  periosteum  from  the  selected 


REPLANTATION,    TRANSPLANTATION,    IMPLANTATION.  243 

place,  through  the  means  of  a  crucial  incision.  Then  with  the 
proper  instruments  the  socket  is  cut  to  a  sufficient  depth  and 
enlarged  as  is  necessary,  the  previously  prepared  tooth  being 
occasionally  lifted  from  the  sterilizing  solution  in  which  it  should 
be  kept,  and  tried  in  to  determine  the  direction,  as  well  as  the 
depth  and  size  of  the  hole,  which  should  not  be  so  large  as  to 
permit  the  root  to  be  loose.  Finally,  the  tooth  is  inserted,  and  a 
proper  splint  or  ligature  used  to  hold  it  immovable.  If  it  does  not 
readily  and  quickly  become  attached  and  within  three  or  four 
days  appear  comparatively  firm,  it  is  better  to  remove  it,  freshen 
the  walls  of  the  socket  with  the  bur,  sterilize  it  again  and  replant 
it;  or,  what  is  better,  obtain  another  tooth  and  insert  that  after 
its  proper  preparation. 

The  operation  is  really  but  a  simple  one,  as  there  are  not  likely 
to  be  any  complications,  unless  in  very  rare  cases  tetanus  might  be 
induced.  Should  there  be  any  indications  of  this,  ten  to  fifteen 
drops  of  belladonna  may  be  administered  every  four  hours.  Care 
should  be  exercised  about  drilling  too  deeply  and  thus  severing 
arteries  or  nerves  that  might  be  avoided.  No  one  should  attempt 
the  operation  unless  he  is  thoroughly  familiar  with  the  anatomy 
of  the  parts,  for  it  is  possible  to  do  serious  injury. 

The  point  of  greatest  interest  lies  in  the  possibility  of  perma- 
nent attachment  and  the  character  of  the  changes  that  are  involved. 
It  does  not  seem  possible  that  there  can  be  any  revivi- 
fication of  tissues  that  perhaps  have  long  been  dead.  As 
for  the  enamel,  the  proportion  of  living  matter  it  contains 
is  too  small  to  be  taken  into  account.  The  dentine  is  in 
precisely  the  same  state  as  in  other  devitalized  teeth  in  which  the 
root  canal  has  been  successfully  filled.  It  is  not  at  all  in  relation 
with  any  of  the  other  tissues  of  the  body,  being  completely 
enveloped  and  segregated  by  the  overlying  enamel  and  cementum. 
The  latter  tissue,  and  the  pericementum,  are  the  only  ones  to  be 
considered,  and  a  little  examination  into  their  probable  state  may 
be  profitable. 

The  studies  of  implanted  or  replanted  teeth  made  after  they 
have  been  subsequently  lost  reveal  no  conditions  that  may  not 
exist  in  those  remaining  in  their  natural  sockets.  They  may  be 
attacked  by  caries  which  will  not  materially  differ  from  that  of 
ordinary   devitalized   teeth.      Into   the   tubules    of   their   dentine 


244 


ORAL    PATHOLOGY   AND   PRACTICE. 


organisms  may  penetrate,  as  in  other  instances  of  tooth  infection. 

(See  Fig.  79.)     There  may  be  melting  down  of  the  intertiibular 

substance,  distention  of  the  tubuli  and  destruction  of  the  dentine 

as  in  the  usual  forms  of  caries.     (See  Fig.  80.)    The  same  minute 

caverns  and  liquefaction  foci  are  formed,  with  the  fracturing  and 

breaking  up  of  the  weakened  tissue,  that  may  be  observed  in 

teeth  that  have  never  been  extracted.     (See   Fig.  81.)     When 

they  are  lost  through  resorption  of  the  cementum  and  dentine 

of  the  root,  the  appearances  indicate  that  it  is  a  process  identical 

with  that  by  which  the  roots  of  deciduous  teeth  are  removed — the 

action  of  the  osteoclasts  or  resorption  cells  that  are  formed.    (See 

Figs.  82  and  83.) 

Fig.  83. 


Resorption  of  the  Roots  of  Deciduous 

^  ,,  ^  Rl-.SCJRl' 1  Kin    ()1-    IiMPLANlhU    1  (JU  1  H  ,    jHUW- 

Teeth  as  Usually  Observed.  ,  ,  , 

INC.  Labial  and  Lingual  Aspects. 

In  the  latter  the  projecting  central  portion 

is  the  gutta-percha  root  filling.     (Practice    of 

Dr.  William  Jarvie.) 

In  all  cases  of  plantation  of  teeth  the  final  success  of  the 
operation  must  depend  either  upon  the  reunion  of  sundered  tissues 
or  the  growing  of  new.  Osteoblasts  may  exist  anywhere  in  the 
substance  of  the  bone,  or  may  be  developed  at  any  point  wdiere 
the  artificial  socket  is  made.  Some  of  them  must  neces- 
sarily be  encountered,  and  they  will  serve  as  the  initial  points  for 
the  growth  of  new  bone.  A  new  periosteum  (or  in  this  case 
pericementum)  must  be  developed  to  form  the  nutritive  organ  of 
the  new  tissue.  The  inflammation  developed  by  the  trauma  results 
in  the  effusion  of  the  lymph  necessary  for  these  new  growths,  and 
thus  the  cavities  in  the  bone  are  filled  with  granulations  as  the 
consequence  of  the  development  of  a  new  pericemental  membrane. 
Without  the  growth  of  new  pericementum  it  is  difficult  to  imagine 
either  the  formation  of  new  tissue  or  the  nutrition  of  that  already 


REPLANTATION,    TRANSPLANTATION,    IMPLANTATION.  245 

in  existence.  Under  favoring  conditions  this  is  as  readily  organ- 
ized as  any  other  tissue,  and  it  would  appear  that  its  formation  must 
be  the  initial  step  in  all  these  conditions. 

Thus  we  can  readily  account  for  the  reconstruction  of  perice- 
mentum and  bone.  The  cementum  of  the  tooth  structure  is 
already  formed.  No  instances  of  any  further  growths  to  it  in 
these  cases  have  been  brought  to  professional  notice.  If  any  such 
do  exist  they  must  appear  as  hypertrophies,  brought  about 
through  the  formation  of  cementoblast  cells  and  their  physiological 
activity,  a  process  that  does  not  seem  probable.  Osteoblasts  may 
be  found,  for  there  is  living  bone,  but  there  is  no  vivified 
cementum. 

It  does  not  appear  probable  that  the  attachment  of  an  im- 
planted tooth  can  be  by  anything  like  ankylosis,  as  has  been  some- 
times urged.  Only  homologous  tissues  will  unite,  and  bone  and 
cementum  are  too  widely  differentiated  ever  to  grow  together. 
Any  such  kind  of  ankylosis,  then,  must  imply  the  formation  of  some 
agglutinating  substance  which  partakes  of  the  structure  of  both 
tissues,  and  which  might  become  continuous  with  the  bone  on 
cne  side  and  unite  with  the  cementum  on  the  other.  But  we 
know  of  no  such  kind  of  hybrid  or  mongrel  tissue,  nor  has  any 
case  of  such  union  been  demonstrated.  It  is  true  that  fractured 
bones  are  joined  by  the  deposition  of  "provisional  callus,"  but 
that  is  formed,  unlike  osseous  tissues  which  have  a  membranous 
genetic  origin,  through  the  calcification  of  a  cartilaginous  matrix, 
while  this  organization  of  new  tissue  must  be  under  the  domination 
of  the  pericemental  membrane. 

If  there  could  be  formed  any  ankylosing  tissue,  it  could  be 
but  temporary,  because  without  a  pericementum  there  would  be 
no  means  by  which  it  could  be  sufficiently  nourished,  and  it  must 
shortly  break  down.  But  it  is  as  true  that  pericementum  may  be 
secondarily  formed  after  its  destruction  as  that  any  other  tissue 
may  be  grown  after  its  partial  loss.  While  it  is  a  fact  that  no  new 
cementum  is  added  to  the  tooth,  nor  can  the  cementum  corpuscles 
be  revivified,  yet  cavities  in  the  investing  bone  may  be  filled  through 
the  action  of  osteoblasts,  and  these  would  imply  the  formation  of  a 
new  periosteum  or  pericementum,  without  which  necrosis  would  be 
the  probable  result.  All  the  circumstances  attending  the  attach- 
ment of  an  implanted  tooth,  and  those  of  its  loss  after  such  fixation. 


246  ORAL    PATHOLOGY   AND   PRACTICE. 

seem  unmistakably  to  point  to  the  formation  of  a  new  pericementum 
and  the  penetration  of  the  cementum  of  the  implanted  tooth  by  the 
fibers  of  Sharpey,  or  their  analogues,  as  in  teeth  of  natural  growth. 
What,  then,  is  the  probable  condition  of  the  cementum  of  an 
implanted  tooth  that  had  for  a  long  time  been  extracted?  Such 
examinations  as  it  has  been  possible  to  make  in  the  implanted 
teeth  that  have  been  lost  and  then  have  fallen  under  observation, 
have  indicated  resorption  rather  than  growth.  It  does  not  appear 
that  the  cementum  lacunae  have  ever  been  refilled  with  living  matter, 
but  that  the  extent  of  revivification  has  been  the  penetration  of  the 
cementum  by  the  transverse  fibers  of  the  pericementum,  which 
thus  holds  the  tooth  firmly  in  place,  for  a  time  at  least,  and  pre- 
serves it  from  retrogressive  changes.  Under  these  circumstances 
that  which  might  naturally  be  expected  too  often  takes  place,  and 
any  unusual  irritation,  or  perhaps  some  nutritional  derangement, 
results  in  the  formation  of  osteoclasts,  with  the  resorption  of  the 
cementum.  This  is  the  usual  process  by  which  an  implanted  tooth 
is  lost.  There  being  no  formation  of  living  matter  within  the 
cementum  cells,  but  simply  the  penetration  of  the  pericemental 
fibers,  the  tooth  only  remains  in  a  state  of  tolerance.  The  usual 
period  of  retention,  when  the  work  is  skillfully  done,  is  sufficient, 
however,  to  justify  the  operation,  when  no  special  service  is 
demanded  aside  from  the  preservation  of  appearances. 


CHAPTER  LIII. 

SYPHILIS:     GENERAL   CONSIDERATIONS. 

The  introduction  of  the  study  of  diseases  like  Syphilis  in  a 
book  of  this  character  may,  by  the  advocates  of  a  restricted  dental 
practice,  be  thought  quite  outside  its  scope.  Were  it  a  strictly 
venereal  disorder  this  would  be  quite  true.  But  when  we  reflect 
that  some  of  the  gravest  manifestations  of  syphilis  are  in  the  oral 
cavity,  and  remember  that  many  of  them  are  highly  infectious, 
and  that  the  danger  to  the  dentist  himself  as  well  as  to  succeeding 
innocent  patients  is  extreme  unless  intelligent  precautions  are 
taken,  the  absolute  necessity  for  a  comprehension  of  the  nature  of 
the  symptoms  manifested  becomes  at  once  apparent.     The  average 


SYPHILIS  :     GENERAL    CONSIDERATIONS. 


247 


dentist  has  heard  and  read  of  the  fearful  consequences  that  may 
be  the  result  of  operations  for  syphilitic  patients,  but  he  has  not 

Fig.  84. 


Chanxre  in  the  Palm. 
The  subject  is  a  dentist  who  gives  a  unique  history.  He  injured  his  hand  a  month  pre- 
vious to  the  appearance  of  the  chancre,  while  filHng  a  tooth  with  gold.  A  plugger  held  in 
the  unaffected  hand  suddenly  slipped,  causing  a  slight  abrasion.  This  healed  in  a  few  days, 
but  subsequently  developed  into  the  condition  shown  in  the  photograph.  The  lesion  was 
about  the  size  of  a  hazelnut,  well  raised,  with  a  surrounding  area  of  induration,  covered  in  part 
with  pale  granulations.  The  axillary  glands  and  those  at  the  elbow  were  enlarged.  Later 
on  a  roseola  appeared  in  the  trunk.     (Dr.  Grover  W.  Wende.) 

the  knowledge  that  would  enable  him  to  recognize  a  case  when 
presented,  or  to  distinguish  between  such  exhibitions  of  its  viru- 


248  ORAL    PATHOLOGY    AND    PRACTICE. 

lence  as  are  dangerous  and  those  which  are  entirely  harmless 
and  non-infective.  He  looks  with  suspicion  upon  any  sore  in 
the  mouth,  and  shrinks  from  a  simple  aphthous  spot  as  involun- 
tarily as  he  would  from  a  pernicious  mucous  plaque. 

On  the  other  hand,  his  ignorance  may  permit  him  to  exhibit 
the  most  reprehensible  recklessness,  and  not  recognizing  upon  a 
poisoned  instrument  that  which  is  deadly  in  its  nature,  carry  in- 
fection to  some  innocent  child,  and  inoculate  it  for  that  which 
shall  blast  its  whole  future  life.  Dr.  G.  W.  Wende,  of  Buffalo, 
has  in  his  large  collection  of  photographs  of  cases  of  syphilitic 
infection  representations  of  some  most  pitiable  instances  of  the 
inoculation  of  dentists  and  surgeons  when  operating  (see  Fig.  84), 
of  chancres  produced  in  children  through  kissing,  of  others  upon 
the  faces  of  patients  through  the  prick  of  a  dentist's  excavator, 
infections  by  means  of  drinking  glasses  and  through  other  un- 
usual and  unsuspected  channels.  The  importance  to  the  dentist, 
then,  of  a  careful  study,  especially  of  the  oral  manifestations  of 
syphilitic  infection,  cannot  well  be  over-estimated.  Nor  can  he 
comprehend  the  significance  of  these  without  some  knowledge 
•of  the  character  and  progress  of  the  disorder.  Hence  the  inclu- 
sion of  some  instruction  in  syphilitic  degenerations  should  form 
a  part  of  the  curriculum  of  dental  study. 

The  introduction  of  the  minutest  amount  of  the  discharge  from 
a  syphilitic  sore,  in  certain  stages  of  the  disease,  will  inevitably 
produce  the  chancre  which  is  the  initial  lesion.  Nothing  short  of 
complete  asepticism  will  prevent  this,  nor  will  any  subsequent 
■sterilization  neutralize  the  poison  when  once  it  has  gained  en- 
trance. Anything,  no  matter  what,  which  will  carry  this  deadly 
virus,  may  be  the  cause  of  inoculation.  It  may  not  even  be 
•essential  to  pierce  the  epidermis.  Any  accidental  sore,  or  fissure, 
'or  abrasion,  may  afford  entrance  to  the  specific  organism,  and 
lience  there  is  no  absolute  safety  from  infection  from  a  syphilitic 
sore,  save  by  the  most  rigid  sterilization  of  everything  brought 
in  contact  with  it,  or  with  fluids  or  matter  infected  by  it.  And 
yet,  surgeons  and  dentists  are  constantly  operating  for  syphilitic 
patients  without  being  inoculated.  There  is  really  no  great  danger 
to  the  operator  provided  he  observes  proper  precautions.  The 
author  has  frequently  worked  for  patients  with  infective  plaques 
in  the  mouth,  without  apprehension.     He  always,  however,  uses 


s^'P[I^J.s:    general  consider. xtioxs.  249 

a  set  of  instruments  that  are  never  employed  for  other  patients, 
and  he  will  not  subject  those  like  the  dental  engine  to  the  risk 
of  infection.  After  such  operations,  napkins,  rubber  dam,  etc., 
are  burned,  while  everything  else  used  is  subjected  to  careful 
sterilization. 

There  are  certain  stages  in  which  syphilitic  discharges  are 
quite  non-infective.  There  are  others  in  which  the  danger,  while 
possible,  is  very  remote,  and  yet  others  in  which  the  slightest 
inoculation  is  positive  and  certain.  And  not  only  may  the  discharge 
from  the  syphilitic  sore  be  infective,  but  the  very  blood  of  the 
S5^philitic  patient  may  be  poisonous,  and  a  single  drop  of  it  may 
produce  a  true  chancre.  The  secretion  from  a  mucous  plaque 
may  be  mixed  with  the  saliva  and  that  be  made  the  medium  of 
infection.  Hence,  in  the  infectious  stages  of  acquired  syphilis, 
prophylaxis  is  of  far  greater  importance  in  the  mouth  than  in  any 
other  anatomical  region.  In  inherited  tertiary  syphilis  there  may 
exist  the  most  repulsive  and  apparently  threatening  sores,  yet 
they  are  wholly  non-infectious.  In  the  acquired  tertiary  form, 
while  there  may  exist  the  possibility  of  infection,  the  danger  is 
very  slight.  Some  of  the  lesions  of  the  secondary  stage  are  as  in- 
fectious as  the  primary  sore,  but  the  ordinary  eruptions  are  harm- 
less. The  initial  lesion  of  primary  syphilis,  the  true  chancre,  no 
matter  what  may  be  its  location,  is  always  deadly  and  its  dis- 
charge inevitably  infective.  Such  apparently  contradictory  condi- 
tions demand  technical  knowledge  of  the  disease  if  the  practi- 
tioner is  to  know  when  and  how  to  operate  with  safety  to  himself 
and  to  others. 

The  oral  lesions  that  are  dangerous,  aside  from  the  primary 
chancre,  which  may  appear  upon  the  lip  or  in  the  mouth,  belong 
to  the  secondary,  the  eruptive  stage,  and  consist  of  the  degenera- 
tions of  mucous  membrane  that  are  analogous  to  those  taking  place 
in  the  skin.  They  do  not  essentially  differ  from  the  eruptions  on 
other  parts  of  the  body,  but  are  merely  modified  by  the  conditions 
existing  in  the  tissues  in  which  they  appear.  Mucous  membrane 
is  the  covering  of  the  internal  parts  of  the  body,  as  the  skin  is  of 
those  which  are  external.  Each  is  continuous  with  the  other,  has 
nearly  the  same  structure,  and  has  like  functions.  Both  are 
covered  with  epithelial  scales,  which  are  continually  exfoliated 
and  as  constantly  renewed.     But  in  place  of  the  sebaceous  and 


250  ORAL    PATHOLOGY   AND    PRACTICE. 

perspiratory  glands  of  the  skin,  the  mucous  membrane  has  mu- 
cous follicles,  whose  secretion  keeps  it  in  a  moist  condition. 

An  eruption  due  to  an  identical  cause  may  present  a  far  differ- 
ent appearance  on  mucous  membrane  from  that  exhibited  upon  the 
external  cuticle.  In  the  mouth,  where  the  secretion  of  the  salivary 
glands  is  added  to  that  from  the  mucous  follicles,  this  variation 
is  very  much  intensified,  and  an  eruption  which  upon  the  skin 
might  present  the  appearance  of  nothing  more  than  maculated 
spots  may  here  exist  as  erosions.  Another,  which  in  the  same 
stage  upon  the  skin  would  present  the  form  of  a  simple  papule, 
in  the  mouth  is  macerated  and  softened  and  irritated  until  the 
papules  break  down  and  appear  as  mucous  plaques.  This  must 
be  heedfully  kept  in  mind  by  the  student,  who  should  not  forget 
that  the  existence  of  a  cutaneous  eruption  will  be  likely  to  appear 
in  the  oral  cavity  as  mucous  plaques  and  eroded  patches.  The 
presence  of  the  former  should  always  prompt  the  practitioner  to 
look  in  the  mouth  for  the  latter.  It  is  impossible  in  a  work  like 
this  to  afford  anything  like  an  exhaustive  study  of  the  subject, 
but  the  author  will  endeavor  to  summarize  the  most  salient  points, 
before  proceeding  to  which  he  has  thought  it  necessary  to  present 
these  sreneral  remarks. 


CHAPTER  LIV. 
SYPHILIS:  THE  PRIMARY  STAGE. 

Syphilis  is  a  constitutional,  infectious  disease,  which  may  be 
acquired  by  direct  contact  or  transmitted  by  a  tainted  parent  to  the 
child,  and  so  received  by  inheritance.  The  virus  is  exceedingly 
virulent  in  character,  and  in  time  affects  every  tissue  of  the  body, 
even  to  the  hair  and  nails.  It  is  believed  to  be  due  to  a  specific 
organism,  though  none  has  been  positively  identified.  As  has 
been  already  said,  while  usually  a  venereal  disease  acquired  by 
sexual  congress,  it  may  be  communicated  to  any  abraded  surface 
by  any  agent  that  will  convey  the  virus.  The  primary  sore  may 
be  upon  the  lips  of  the  person  affected,  and  he  or  she  may  com- 
municate it  by  kissing,  or  it  may  be  carried  by  surgeons'  or  den- 
tists' instruments,  or  even  by  drinking  vessels. 

While  the  most  malignant  of  diseases,  there  is  none  which  so 


syphilis:     the  primary  stage.  251 

directly  and  unmistakably  yields  to  properly  directed  medication. 

It  is  the  belief  of  many  physicians  that  drugs  have  no  curative 
power,  but  that  all  recovery  from  diseased  conditions  is  due  to 
functional  activities,  and  that  medicines  can  do  no  more  than  to 
fortify  nature  to  support  vitality,  to  invigorate  function.  The 
fact  that  syphilis  is  positively  curable  by  medication,  that  it  is 
indisputably  amenable  to  specific  agents,  is  the  insuperable  ob- 
stacle to  the  acceptance  of  the  dogma  that  drugs  have  no  imme- 
diate remedial  action,  but  that  all  cures  are  through  the  vis  medi- 
catrix  naturcc — the  recuperative  or  healing  force  inherent  in  func- 
tion. 

It  is  only  when  acquired  by  inoculation  that  syphilis  presents 
all  its  characteristic  phenomena.  When  it  is  congenital,  i.e., 
inherited  from  syphilitic  parents,  it  does  not  pass  through  all  the 
incubative  stages,  and  is  without  the  initial  lesion  or  sore.  Our 
attention  therefore  will  primarily  be  directed  to  acquired  syphilis. 

The  primary  sore  which  is  produced  by  inoculation  with  the 
syphilitic  virus  is  called  the  Chancre.  It  is  located  at  the  point  of 
infection,  and  is  single.  (See  Fig.  84.)  It  does  not  make  its 
appearance  immediately  after  infection,  buc  there  is  a  period  which 
varies  in  length  from  ten  to  sixty  days,  during  which  the  specific 
virus  is  insensibly  working,  before  an  unmistakable  lesion  is  seen. 
This  is  called  "the  period  of  first  incubation." 

The  chancre,  or  primary  sore,  presents  certain  characteristics 
which,  while  not  affording  an  infallible  criterion  in  diagnosis  as  to 
its  nature,  yet  when  linked  with  the  whole  clinical  history  should 
prevent  any  egregious  errors.  But  it  should  not  at  once  be  sus- 
pected that  every  sore  in  the  mouth,  upon  the  lips,  or  even  the 
genitals,  is  of  syphilitic  origin,  without  confirmatory  testimony. 
Many  an  innocent  person  has  rested  under  suspicion  because  of  the 
appearance  of  a  papule,  vesicle,  or  pustule  upon  some  portion  of  the 
body.  Dentists  should  be  especially  careful  in  their  deductions, 
and  should  not  precipitately  pronounce  a  lesion  "specific"  until  it 
is  unmistakably  proved  such. 

It  is  a  very  delicate  matter  for  a  practitioner  to  whom  applica- 
tion for  professional  services  is  made  by  a  respectable  person, 
in  whose  mouth  or  upon  whose  lips  there  exists  a  suspicious  sore, 
to  ask  any  pointed  questions  as  to  its  origin.  And  yet  it  is  of  the 
utmost  importance,  not  only  to  the  dentist  personally,  but  to  his 


252  ORAL    PATHOLOGY    AND    PRACTICE. 

Other  patients,  that  he  should  know  the  truth.  He  cannot  com- 
mence any  special  inquiries  until  he  has  something  definite  upon 
which  to  found  them,  for  an  innocent  person  is  likely  to  consider  it 
a  mortal  offense  if  he  or  she  is  suspected  of  infection  with  so  loath- 
some a  disorder.  Fortunately,  it  is  not  usual  for  lesions  to  make 
their  appearance  in  or  about  the  mouth  until  the  existence  of  the 
disease  is  well  known  to  the  patient,  and  before  that  time  arrives 
he  or  she  has  probably  been  under  the  care  of  a  physician.  Know- 
ing the  exigencies  of  the  case,  they  will  then  in  most  instances  be 
ready  to  respond  at  once  to  guarded  inquiries.  But  it  should  be 
comprehended  that  these  remarks  do  not  apply  when  the  chancre 
originally  appears  about  the  mouth.  It  is  only  when  the  oral 
indications  are  secondary  that  the  patient  himself  will  comprehend 
their  character  and  significance. 

The  first  prerequisite  to  the  identification  of  a  syphilitic  sore 
will  be  found  in  the  history  of  the  case.  If  it  appears  upon  the 
genitals,  there  must  have  been  an  exposure  through  an  impure 
connection.  It  is  needless  to  say  that  while  the  physician  patiently 
listens,  without  expressing  any  dissent,  to  tales  of  water-closet 
infection,  he  will  in  his  mind  give  them  just  the  weight  to  which 
they  are  entitled.  If  the  primary  sore  appears  about  the  mouth 
there  must  have  been  a  history  of  infection  in  some  way,  and  that 
may  be  even  less  creditable  than  when  the  inoculation  is  through 
natural  sexual  intercourse.  On  the  other  hand,  it  may  be  by 
entirely  innocent  means.  It  may  tax  the  ingenuity  of  the  practi- 
tioner to  discover  some  way  in  which  to  determine  this  point. 

The  chancre,  which  is  positively  indicative  of  syphilitic  poison- 
ing, presents  these  three  distinguishing  features : 

0.     An  incubative  period  preceding  its  appearance. 

b.  Certain  special  characteristic  appearances. 

c.  Glandular  enlargements  and  indurations. 

The  period  of  incubation,  as  has  already  been  stated,  is  an 
average  of  about  twenty-one  days.  But  it  should  not  be  under- 
stood that  symptoms  of  infection  will  always  manifest  themselves 
after  exposure.  Some  people  seem  to  have  almost  an  entire  immu- 
nity to  ordinary  inoculation,  and  may  escape  when  another  would 
not.  There  are  conditions  of  the  system  in  which  one.  is  more 
liable  to  infection  than  in  others,  as  is  the  case  with  other  commu- 
nicable disorders,  so  that  a  person  may  possibly  pass  through  the 


SYPHILIS  :       THE    PRIMARY    STAGE.  253. 

fire  more  than  once  without  being  burned.  Very  old  and  very 
young  persons  are  especially  liable  to  infection,  because  of  their 
weak  resisting  powers;  and  the  same  may  be  said  in  anemia,, 
malaria,  alcoholism,  and  other  atonic  conditions. 

The  first  appearance  of  the  chancre  is  usually  as  some  kind  of  a. 
papilla  or  pimple  situated  at  the  point  of  infection  and  varying  in. 


Chancre  on  the  Upper  Lip.    Commencing  to  Ulcerate.     (Weiide.) 

size.  It  may  never  be  large  enough  to  attract  special  attention,, 
but  usually  it  continues  to  increase  until  it  is  as  large  as  a  dime. 
It  is  dark  in  color,  elevated  very  little  above  the  general  surface,, 
and  is  imbedded  in  an  indurated,  subcutaneous,  infiltrated  mass,, 
which  between  the  thumb  and  finger  feels  like  cartilage.  This 
hard  base,  with  the  entire  absence  of  pain,  burning,  itching  or 
fever,  and  with  the  glandular  afifection  which  is  soon  manifest,. 


254  ORAL    PATHOLOGY   AND   PRACTICE. 

may  be  considered  pathognomonic  of  the  syphilitic  infection. 
After  about  ten  days  the  epitheha  upon  the  surface  of  the  chancre 
softens  and  it  becomes  covered  with  a  gray  film.  Then  the  central 
point  ulcerates  and  discharges  a  serum  which  is  highly  infectious. 
(See  Fig.  85.) 

Very  soon  after  the  appearance  of  the  chancre  the  nearest 
lymphatic  glands  become  enlarged  and  indurated,  thus  indicating 
the  beginning  of  the  constitutional  affection.  If  the  primary  in- 
oculation is  venereal,  the  inguinal  glands  will  be  the  ones  first 
attacked,  and  form  what  is  called  the  indolent  bubo.  A  gland 
may  even  break  down  and  suppurate,  and  cause  an  ulcerative 
bubo.  If  the  initial  point  of  lesion  is  about  the  mouth,  the  sub- 
maxillary salivary  gland  is  affected,  and  may  be  felt  as  a  swollen 
hard  lump  beneath  the  jaw.  A  little  later  the  cervical  lymphatics 
become  engaged,  and  may  be  felt,  or  even  seen,  presenting  their 
characteristic  appearance.  In  suspected  chancre  of  the  lip  the 
■condition  of  the  sub-maxillary  gland  will  be  a  great  help  in  mak- 
ing a  diagnosis. 

The  chancre  is  single.  The  instances  in  which  two  or  more 
appear  are  very  rare.  It  is  no"^  auto-inoculable,  and  in  this  respect 
materially  differs  from  chancroid,  or  false  chancre.  It  usually  heals 
readily,  without  any  scar  or  deep  mark,  and  that  without  special 
local  treatment.  The  time  of  its  duration  is  somewhat  uncertain, 
and  depends  upon  the  type  which  the  disease  assumes.  Very 
young  and  very  old  persons  are  likely  to  be  more  violently  at- 
tacked, and  the  chancre  may  in  these  instances  persist  longer. 
The  same  may  be  said  of  atonic  and  anemic  individuals,  or  those 
suffering  from  tuberculosis,  malaria,  or  alcoholism.  In  these  cases 
the  whole  affection  is  likely  to  assume  a  malignant  type,  and  the 
sore  may  continue  until  the  appearance  of  the  secondary  symptoms. 

In  the  primary  stages  mercury  seems  almost  a  specific,  and  if 
the  system  will  bear  it  in  sufficient  quantities  the  progress  of  the 
infection  is  stayed.  Sometimes,  however,  this  remedy  produces 
such  derangements  that  it  is  impossible  to  continue  its  free  use, 
and  the  doses  must  be  reduced.  Ptyalism  with  intense  glossitis 
may  supervene,  and  other  general  disturbances  may  be  of  such  a 
grave  character  that  it  will  be  found  imprudent  to  push  it  suffi- 
ciently to  neutralize  the  virus  completely.  The  chancre  should 
be  treated  antiseptically,  and  if  necessary  cauterized  to  hasten  the 
healing. 


THE    SECONDARY   STAGE   OF    SYPHILIS.  255 

CHAPTER    LV. 

THE  SECONDARY  STAGE  OF  SYPHILIS. 

With  the  disappearance  of  the  primary  sore  commences  the 
second  period  of  incubation,  or  that  in  which  the  virus  is  insid- 
iously but  steadily  invading  all  the  tissues  of  the  body.  This 
period,  like  the  first,  is  variable,  and  may  extend  from  three  weeks 
to  six  months,  or  even  more,  seven  weeks  being  about  the  aver- 
age. At  the  end  of  that  time  there  commences  a  train  of  symp- 
toms which  denote  that  the  infection  has  passed  beyond  the 
local  stage,  and  through  the  lymph  channels  has  reached  every 
organ  and  tissue  of  the  body.  During  this  second  period  of 
incubation  the  uninformed  victim  might  imagine  the  disease 
cured,  but  that  is  by  no  means  the  case.  The  virus  is  very  active, 
though  without  any  outward  manifestations,  until  it  exhibits  its 
destructive  energy  in  constitutional  symptoms. 

The  indication  of  the  completion  of  the  second  period  of  incu- 
bation and  the  commencement  of  the  second  stage  of  syphilis  is  the 
appearance  of  the  so-called  syphilides,  or  syphilodermata.  These 
are  the  eruptions  of  various  kinds  which  appear  upon  different 
parts  of  the  body.  The  first  of  these  is  most  commonly  a  kind 
of  roseola,  or  redness  of  the  skin,  which  covers  the  thorax,  occa- 
sionally the  abdomen,  and  sometimes  nearly  the  whole  body, 
very  rarely  appearing  on  the  face.  It  is  symmetrical,  occurring 
on  both  sides  of  the  median  line  alike,  and  not  coming  as  irregular 
desultory  blotches.  Like  the  chancre,  which  marks  the  primary 
stage,  this  eruption  is  without  any  functional  disturbance,  and 
in  this  absence  of  burning  or  itching  or  fever  differs  from  all  other 
skin  eruptions.  The  roseola  is  entirely  superficial  and  spontane- 
ously disappears  after  a  variable  period,  to  be  succeeded  by  other 
forms  of  eruption. 

The  syphilides  of  the  secondary  stage  appear  on  both  the 
skin  and  the  mucous  membrane,  and  may  be  erythematous  (red 
blotches),  macular  (pigmented  spots),  squamous  (scaly),  vesicular 
(sac-like),  pustular  (pimples),  tubercular  (nodules),  rupial 
(crusts),  or  they  may  assume  any  intermediate  form.  The  syphilitic 
sore  throat,  which  usually  accompanies  any  of  these  forms,  is 
really  the  eruption  upon  the  mucous  membrane  of  the  pharynx. 


256 


ORAL    PATHOLOGY    AND    PRACTICE. 


The  mucous  plaques,  or  mucous  patches  of  the  mouth,  are  the 
same  eruptions,  changed  in  their  appearance  by  the  character  of 
the  tissue  in.  which  they  are  manifested,  and  by  their  environ- 
ments or  surroundings. 

For  the  purposes  demanded  by  the  present  study  all  the  syphil- 
ides  may  be  divided  into  three  classes — the  macular,  the  papular, 

Fig.  86. 


Mucous  Plaque  or  Patch  (Papulo-krosive  Plaque)  upon  the  Tongue.     (Wende.) 

and  the  pustular.  The  first  when  they  appear  upon  external  cuta- 
neous surfaces  are  primarily  only  pigmented  spots,  like  freckles, 
not  raised  above  the  surrounding  tissues,  tending  to  circular 
groupings,  and  of  a  coppery  color.  They  may  entirely  disappear 
and  be  succeeded  by,  or  they  may  assume,  the  papillary  form,  and 
spread.  They  appear  innocent  and  give  the  patient  no  incon- 
venience. 


THE    SECONDARY   STAGE   OF    SYPHILIS.  257 

In  the  mouth  and  upon  mucous  membrane  the  eruption  is 
usually  first  seen  in  this  macular  form, — that  is,  of  reddish  or  copper 
colored  spots,  not  raised  above  contiguous  surfaces.  They  may  be 
observed  over  the  arch  of  the  soft  palate,  upon  the  tongue  and 
pillars  of  the  fauces,  on  the  buccal  surfaces,  and  along  the  mucous 
membrane  where  it  doubles  upon  itself  and  where  it  is  hidden  from 
ordinary  observation.  Especially  are  they  apt  to  appear  beneath 
the  tongue  and  upon  the  folds  of  the  membrane  in  that  locality. 
They  may  be  the  size  of  the  finger  nail  or  they  may  be  mere 
punctate  spots.  Usually  they  very  soon  disappear  and  are  suc- 
ceeded by  the  papules. 

The  papular  form  is  that  which  succeeds  the  macular.  It  con- 
sists of  reddish  pimples  appearing  upon  the  skin,  vt^hich  from  a 
single  point  spread,  or  from  a  number  such  become  confluent. 
Gradually  these  papules  become  more  pronounced  and  separate, 
certain  of  them  perhaps  degenerating  and  assuming  an  aggra- 
vated appearance,  while  between  them  the  others  disappear  or 
become  scaly,  the  surface  being  exfoliated,  and  so  the  eruption 
takes  upon  itself  the  third  or  pustular  form.  This  is  the  most 
common  manner  of  progression,  but  in  some  malignant  instances 
the  macular  seems  very  quickly  to  degenerate  into  the  pustules, 
without  the  appearance  of  papules. 

In  the  mouth  the  papular  form  assumes  different  characteris- 
tics. Instead  of  gradually  becoming  pustular,  the  surfaces  are 
macerated  in  the  oral  fluids  and  soon  appear  as  erosions.  There  is  an 
infiltration  into  the  sub-mucous  tissue,  and  this  causes  a  raising 
of  the  edges,  while  the  sore  is  imbedded  in  a  stroma  of  the  thick- 
ened, slightly  sclerotic  base.  The  center  softens  and  is  covered 
with  a  grayish  film,  which  discharges  a  sanious,  highly  infective 
fluid.  This  sore  will  have  sharply  defined  edges,  a  dark  red 
aureola  surrounding  it,  an  excavated  surface  and  a  crater-like 
general  aspect,  with  necrotic  tissue  on  or  in  it,  when  seen  in  its 
worst  phases.  In  less  pronounced  cases  it  may  be  only  a  round 
or  ovoid  sore  of  a  yellowish  color,  no  aureola,  with  but  a  slight 
excavation  and  a  discharge  which  is  not  as  profuse,  but  is  quite 
as  infectious  as  is  the  other. 

The  appearances  described  in  the  preceding  paragraph  form 
what  are  called  the  "mucous  plaques"  or  "mucous  patches"  of  sec- 
ondary  syphilis.     (See   Fig.   86.)     They   are  the   oral   syphilides 


258  ORAL    PATHOLOGY    AND    PRACTICE. 

which  the  dentist  should  most  carefully  guard  against.  They 
will  most  frequently  be  observed  on  the  borders  of  the  tongue, 
but  may  be  found  anywhere  on  the  oral  mucous  membrane,  the 
uvula,  in  the  pharynx,  and  where  two  surfaces  come  in  contact. 
They  may  degenerate  into  deep  ulcers  and  be  accompanied  with 
acute  glossitis,  or  swelling  of  the  tongue,  which  may  thus  press 
against  the  teeth  and  its  edges  and  be  made  to  assume  an  indented 
or  scalloped  appearance.  These  phenomena  disappear  sponta- 
neously in  time,  sometimes  leaving  deep  furrows  as  the  result 
of  the  glossitis  which  may  be  present. 

The  pustular  form  of  the  eruptions  upon  the  skin  may  be 
degenerations  of  the  papules,  or  the  latter  may  disappear  entirely 
to  be  succeeded  by  the  pustules.  Gradually  the  papules  may  become 
more  pronounced  and  some  of  them  may  take  on  the  pustular 
form,  softening  at  the  center  and  discharging  a  sanious  fluid 
which  is  exceedingly  infective.  These  may  become  aggravated 
and  ulcerate  and  be  very  offensive.  If,  on  the  other  hand,  the 
-disease  does  not  assume  a  malignant  type,  they  may  dry  up  and 
.disappear  without  ulceration.  They  may  appear  on  the  scalp  or 
ilower  extremities  as  cone-like  elevations,  giving  rise  to  large, 
irregularly, shaped  ulcers,  secreting  a  bloody  pus  that  dries  up 
and  forms  dark  brown  or  black  crusts,  or  they  may  dry  down  and 
exfoliate  the  surface  in  the  shape  of  scales,  thus  forming  the 
squamous  syphilides  that  may  possibly  be  mistaken  for  psoriasis, 
or  itch.  It  may  thus  be  seen  that  the  eruptions  of  secondary 
syphilis  very  widely  differ  in  appearance,  depending  upon  the 
.•constitutional  condition  of  the  patient  and  the  type  of  the  disease. 

This  pustular  form  does  not  offer  the  same  phenomena  in  the 
oral  cavity.  On  mucous  membrane  the  mucous  plaques  may  ulcerate 
and  cause  considerable  pits,  but  they  do  not  rise  into  cone-like  eleva- 
tions. As  already  asserted,  there  is  no  essential  difference  in  the 
conditions,  the  mucous  plaques  or  patches  being  the  analogues 
of  the  papular  eruptions  upon  the  skin,  and  their  ulceration  an- 
swering to  the  pustules  which  appear  on  external  cutaneous  sur- 
faces. AVhen  the  one  is  present  the  other  may  be  looked  for  in 
its  proper  place,  the  difference  in  manifestation  being  due  to  the 
modifications  of  the  tissue. 

During  all  this  time  the  enlargement  and  induration  of  the 
-lymph  glands  lias  been  increasing  and  extending.    They  may  proba- 


TERTIARY    AND    HEREDITARY    SYPHILIS.  259 

bly  be  felt  at  this  time  along  the  posterior  border  of  the  sterno- 
cleido-mastoid  muscle,  the  other  cervical  glandular  regions,  and 
those  of  the  supraclavicular  and  epitrochlear  localities.  They 
vary  in  size  from  that  of  a  pea  to  a  pigeon's  egg,  are  round,  hard, 
and  painless. 

At  the  same  time  the  constitutional  disturbance  begins  to 
manifest  itself  in  fever,  the  bodily  temperature  rising  perhaps  to 
102°  r.,  in  pains  of  neuralgic  or  rheumatic  character,  and  in  severe 
headaches.  There  will  be  restlessness  and  sleeplessness,  all  the 
symptoms  being  worse  at  night,  and  exacerbated  by  fatigue  or  by 
exposure  to  extremes  of  temperature,  by  wet  feet  or  any  unusual 
exposure.  The  virus  is  infecting  the  deeper  organs  and 'interfer- 
ing with  functional  activity. 

It  should  always  be  borne  in  mind  that  the  characteristic  secre- 
tions of  the  syphilodermata  are  infectious  in  the  highest  degree. 
The  blood  at  this  time,  as  has  already  been  intimated,  may  con- 
tain the  virus  to  such  an  extent  that  it  becomes  noxious,  and 
inoculation  with  it  may  produce  the  true  phagedenic  chancre. 
The  saliva  may  be  mixed  with  the  discharges  from  mucous 
plaques  and  also  be  capable  of  communicating  the  disease.  The 
whole  system,  in  fact,  is  a  loathsome,  pestilential  mass  of  corrup- 
tion, revolting  to  the  sufferer  himself  and  abhorrent  to  others. 


CHAPTER     LVI. 
TERTIARY  AND  HEREDITARY  SYPHILIS. 

Tertiary  Syphilis  is  the  final  result  of  the  specific  infection. 

It  is  a  breaking  down  of  the  tissues  under  the  degenerative  process, 
and  is  characterized  by  a  worse  series  of  syphilides,  by  necrosis  of 
the  hard,  and  ulceration,  sloughing,  and  perhaps  gangrene  of  the 
soft  tissues.  It  is  a  process  of  general  destruction,  and  some  of  its 
forms  are  repulsive  in  the  extreme.  The  discharges  are  not, 
however,  of  such  an  infectious  nature,  and  hence  it  is  of  less  interest 
to  dentists  than  the  earlier  forms  of  syphilis,  but  it  should  not  be 
imagined  that  they  are  wholly  without  danger. 

The  period  of  incubation  between  the  secondary  or  eruptive 
and  the  tertiary  or  constitutional  stages  is  very  uncertain.     Some- 


2t)0  ORAL    PATHOLOGY    AND    PRACTICE. 

times  the  latter  succeeds  almost  directly  upon  the  heels  of  the 
former,  and  in  other  instances  years  may  elapse  after  the  disap- 
pearance of  the  syphiHdes  before  tertiary  symptoms  become 
manifest.  Dr.  G.  W.  Wende,  of  the  University  of  Buffalo,  reports 
one  case  in  which  only  four  weeks  elapsed  between  the  initial 

Fig.  87. 


Gumma  upon  the  Dorsum  of  the  Tongue  (Gummatous  Infiltration). 
(Wende.) 

sore  and  the  appearance  of  tertiary  symptoms.  In  four  months 
syphilitic  necrosis  had  eaten  away  nearly  all  the  bones  of  the 
face,  destroyed  the  sight,  and  almost  blotted  out  every  feature. 
The  author  saw  cases  in  the  island  of  Cuba  which  assumed  such 
a  maHgnant  form  that  there  were  no  marked  stages  or  periods, 


TERTIARY    AND    HEREDITARY    SYl'HIMS. 


261 


the  one  succeeding  the  other  so  quickly.  Indeed,  hospital  sur- 
geons in  Havana  report  that  a  typical  form  there  is  almost  or  quite 
incurable. 

The  syphilides  of  the  tertiary  stage  commence  with  the  appear- 
ance of  tubercles  or  gumma,  the  former  being-  in  the  skin  or  mucous 


Fig. 


Toads-Back  Appearance  in  Syphilis. 

Gummatous    Infiltrations   (papulo-hypertrophies)     producing   the     so-called    toad's-back 
appearance.     (Weiide.) 


membrane,    while    the    latter    are    subcutaneous    or    submucoid. 

The  advent  of  either  in  syphilitic  patients  is  an  indication  that 
the  disease  has  passed  the  eruptive  or  secondary  period,  and  has 
reached  the  tertiary  or  constitutional  stage.    Tubercles  are  gran- 


262  ORAL    PATHOLOGY   AND    PRACTICE. 

tilar  nodosities,  usually  very  small  and  numerous,  which  may  be 
felt  in  the  epidermis.  The  gumma  are  thickened,  swollen  masses 
in  the  tissues  beneath  the  surface,  and  are  caused  by  infiltrations 
into  the  cellular  structure.  (See  Figs.  87  and  88.)  The  latter 
usually  appear  as  circumscribed,  firm  nodules,  varying  in  size  from 
that  of  a  small  cherry  to  that  of  an  orange.  At  first  the  skin  or 
mucous  membrane  is  uncolored,  but  later  it  is  apt  to  change  to  livid 
or  purple,  becoming  thin  at  the  apex  and  finally  ulcerating.  The 
gumma  are  not  ordinarily  numerous,  seldom  exceeding  three  or 
four  in  one  subject.  They  usually  leave  a  deep  and  abiding  scar. 
When  they  appear  in  the  roof  of  the  mouth,  or  on  the  turbinated 
or  palate  bones,  they  may  result  in  necrosis,  with  perforation  and 
destruction  of  those  bones. 

The  tubercular  deposits  are  of  special  interest  to  the  practi- 
tioner from  the  fact  that  they  ordinarily  prohibit  surgical  opera- 
tions. 

The  condylomata,  or  venereal  warts,  are  morbid  growths, 
the  result  of  syphilitic  infection  in  its  later  stages,  but  as  their 
observation  will  seldom  come  within  the  province  of  the  dentist, 
they  need  not  be  considered  here. 

There  may  be  leucoplakia  of  the  dorsum  of  the  tongue,  which 
is  characterized  by  the  presence  of  pearly  or  bluish  white  patches 
upon  its  surface.  This  is  a  symptom,  however,  upon  which  too 
much  dependence  cannot  be  placed,  as  it  may  be  only  the  effect  of 
excessive  pipe-smoking  or  the  wearing  of  an  artificial  denture. 

The  chancroid,  or  soft  chancre,  is  a  sore  which  does  not  carry 
in  its  train  any  of  the  constitutional  complications  of  the  true  Hun- 
terian  chancre.  It  is  of  a  pustular  nature,  with  a  secretion  that  is 
peculiarly  infectious,  but  which,  unlike  that  of  the  true  chancre,  is 
auto-inoculable;  that  is,  it  infects  the  person  in  whom  it  exists  at 
any  new  point  with  which  it  comes  in  contact,  making  another 
chancroidal  sore.  Hence  chancroids  are  usually  multiple,  while 
the  chancre  is  single.  Chancroids  very  rarely  appear  elsewhere 
than  upon  the  genitals,  and  produce  no  oral  lesions  whatever. 

Hereditary  or  Congenital  Syphilis. 

That  children  may  inherit  this  dread  disease  from  either  parent 
is  a  well-known  fact.  It  appears  under  such  conditions  only  in  its 
tertiary  form.      There  is  no  chancre,  and  there  are  none  of  the 


TERTIARY    AND    HEREDITARY    SYPHILIS.  263 

syphilides  belonging  to  secondary  syphilis,  and  hence  there  is  no 
danger  of  the  infection  of  others.  The  syphilitic  father  may 
transmit  the  disease  without  infecting,  the  mother,  and  vice  versa. 
If  a  mother  acquires  syphiHs  after  her  impregnation,  she  may 
•transmit  the  disease  to  the  fetus  through  the  placental  circulation. 
A  healthy  mother  who  gives  birth  to  a  child  inheriting  syphilis 
from  the  father  may  herself  be  infected,  although  the  disease  will 
be  likely  to  assume  a  modified  form.  When  there  is  impregnation, 
either  of  the  parents  being  afflicted  with  recent   syphilis,   it  is 

Fig.  89. 


Hutchinson  Teeth  when  Recently  Erupted. 

Fig.  90. 


Hutchinson  Teeth  Later  in  Life. 

usually  fatal  to  the  fetus,  either  before  or  shortly  after  birth.  The 
longer  the  time  between  the  infection  and  the  impregnation,  the 
less  will  be  the  chance  of  transmittance,  or  the  milder  the  form 
that  the  disease  will  take,  especially  when  the  parents  have  been 
under  treatment. 

The  usual  indications  of  inherited  or  congenital  syphilis  are 
nasal  catarrh  (snuffles),  erythematous  eruptions,  especially  on  the 
abdomen,  mucous  patches,  cracks  at  the  corners  of  the  mouth  which 
refuse  to  heal,  poor  development  both  physically  and  mentally,  and 
bad  nourishment.  Sometimes  the  infant  is  born  with  these  indica- 
tions of  its  heritage,  while  in  other  instances  none  of  them  make 
their  appearance  for  weeks,  and  the  anxious  parents  are  led  to 
imagine  that  their  offspring  has  escaped  the  taint,  until  a  tell-tale 
eruption  destroys  their  hopes. 


264  ORAL    PATHOLOGY   AND   PRACTICE. 

Hutchinson  believed  that  a  peculiar  formation  of  the  teeth  is 
indicative  of  congenital  syphilis.  This  consists  in  a  variation 
in  the  shape  and  formation  of  the  central  incisors,  in  which  they 
are  narrowed  at  the  point  and  have  a  peculiarly  crescentic  incisive 
edge.  (See  Figs.  89  and  90.)  That  the  so-called  Hutchinsonian 
teeth  are  pathognomonic  signs  of  syphilis  is  denied  by  very  many, 
and  they  certainly  are  found  where  there  are  no  other  indications 
of  this  diathesis.  But  most  syphilologists  are  agreed  that  when 
they  are  accompanied  by  interstitial  keratitis  and  congenital  deaf- 
ness they  may  be  considered  as  reliable  indications. 

Fig.  91. 


Hutchinson  Teeth  in  a  Case  in  which  there  was  a  History  of  Syphilis. 


Fig.  92 


Typical  Hutchinson  Teeth  in  which  there  was  No  Possibility 
OF  Inherited  Taint. 

That  the  so-called  Hutchinsonian  teeth  are  not  an  infallible 
sign  of  inherited  syphilis  appears  to  be  conclusively  demonstrated 
by  Dr.  E.  L.  Keyes,  in  the  Dental  Cosmos,  Periscope,  Vol. 
XXVIL,  page  570.  A  cast  of  the  teeth  of  a  patient  then  suffering 
from  secondary  syphilides,  the  primary  sore  having  disappeared 
but  a  few  weeks  previously,  shows  the  typical  Hutchinsonian 
central  incisors.  Of  course,  inherited  tertiary  syphilis  was  in 
this  instance  impossible.      (See  Fig.  92.) 

The  prognosis  in  inherited  syphilis  is  much  more  grave  than  in 
the  acquired  form.  From  one-third  to  one-half  of  all  syphilitic 
children  die  before  reaching  adult  life. 


SYPHILIS    OF   THE    MOUTH    AND   lONGUE.  265 

The  first  symptoms  of  inherited  syphilis,  the  early  syphilides, 
usually  appear  within  the  first  three  months.     If  an  infant  arrives 

at  the  age  of  six  months  without  exhibiting  any  of  the  indications 
of  syphihs,  it  may  be  safely  assumed  that  it  is  heahhy. 

In  all  the  later  forms  of  syphilis  almost  the  sole  remedy  upon 
which  reliance  is  placed  is  iodide  of  potassium.  Indeed,  this  is 
usually  supposed  to  be  a  specific  if  administered  in  sufficient  quanti- 
ties. There  is  no  Hmit  to  the  size  of  the  dose,  save  the  abihty  of  the 
patient  to  bear  it.  Sometimes  it  induces  functional  disturbances 
of  so  grave  a  character  that  its  use  must  positively  be  intermitted 
or  the  amount  given  reduced,  and  in  such  instances  it  may  be 
impossible  to  withstand  the  progress  of  the  disease.  But  if  the 
patient  can  bear  enough  of  it,  and  its  exhibition  is  persisted  in 
long  enough,  a  cure  is  usually  certain. 


CHAPTER     LVIL 

SYPHILIS  OF  THE  MOUTH  AND  TONGUE:  RECAPITULATION. 

It  was  necessary  to  investigate  the  pathological  changes  that 
take  place  in  syphilitic  affections  before  its  manifestations  could 
be  comprehended,  or  recognized  when  seen.  If  the  nature  of  the 
syphilides  is  not  learned,  the  dentist  will  not  be  prepared  to  under- 
stand their  import  when  he  meets  them  in  practice.  But  it  will  be 
the  oral  phenomena  that  will  chiefly  concern  him,  and  hence  these 
should  be  awarded  special  attention,  because  of  the  possibilities  of 
the  transmission  of  the  disease  through  his  instrumentality. 

The  practitioner  has  already  been  cautioned  against  jumping 
to  the  conclusion  that  every  mucous  patch  in  the  mouth,  or  every 
indurated  sore,  has  a  specific  origin.  Any  excoriation  of  the 
mucous  surface  may  be  greatly  aggravated  by  special  irritants  that 
are  common  in  the  mouth.  The  chewing  and  smoking  of  tobacco, 
the  holding  of  pipes,  cigars,  and  cigar-holders,  the  drinking  of 
hot  and  iced  fluids,  may  intensify  a  local  irritation  until  it  assumes 
a  very  suspicious  aspect.  In  the  same  manner  syphilitic  sores  of 
the  mouth  may  take  upon  themselves  an  irritated  character  or 
appearance.  But  it  should  be  borne  in  mind  that  these  aggrava- 
tions do  not  in  essence  differ  from  the  same  morbific  changes 
•occurring  in  other  parts  of  the  body. 


266  ORAL    PATHOLOGY    AND    TRACTICE. 

Chancres  occurring  upon  the  tongue  or  in  the  oral  cavity^ 
although  somewhat  modified  by  their  surroundings,  present  essen- 
tially the   same   characteristics   as  when  they  appear   elsewhere. 

The  same  may  be  said  of  the  roseola  or  maculae,  the  papules,  pus- 
tules and  ulcers  which  have  already  been  considered.  Rough  or 
carious  teeth  may  aggravate  them,  and  modify  their  appearance, 
but  they  will  not  destroy  their  leading  characteristics.  As  a  rule, 
the  syphilitic  lesions  of  the  mouth  are  of  a  moist  rather  than  a  dry 
nature,  and  usually  assume  the  form  of  mucous  patches. 

In  the  early  stages  of  secondary  syphilis,  the  eruption  may 
appear  in  the  mouth  as  well-defined  areas  of  a  dark  red  color,  upon 
the  soft  palate,  tongue,  pillars  of  the  fauces,  and  along  the  gingival 
labial  borders.  These  may  be  of  any  size,  from  mere  points  to 
blotches  covering  the  whole  surface.  But  they  will  retain  the  sym^ 
metrical  appearance  of  the  cutaneous  eruptions,  and  will  usually  be 
seen  upon  both  sides  of  the  median  line.  Like  those  of  the  surface, 
they  may  disappear  after  proper  treatment,  or  they  may  form  the 
basis  for  further  degenerations.  They  usually  become  eroded  to  a 
greater  or  less  extent,  this  probably  being  due  to  local  irritation. 

The  papular  syphilide  of  the  cutaneous  surface  is  represented 
in  the  mouth  by  mucous  patches  or  moist  papules.  These  may  be 
single  or  multiple,  and  they  are  usually  well  defined,  varying  in  size 
from  a  single  point  to  that  of  a  quarter  dollar.  They  are  at 
first  red  in  color,  but  soon  assume  a  whitish  appearance,  looking 
as  if  the  mucous  membrane  had  been  cauterized  with  nitrate  of 
silver.  They  may  be  raised  above  the  general  level,  and  are 
more  or  less  painful.  Two  of  them  may  perhaps  be  seen  facing 
each  other  on  membranes  that  are  in  contact,  like  the  surfaces  just 
back  of  the  last  molar  tooth,  or  those  of  the  cheek  and  beneath  the 
tongue. 

The  ulcerative  lesions  are  usually  the  further  breaking  down 
of  the  mucous  patches  or  gumma,  and  their  deep  erosion  until  they 
form  considerable  caverns  in  the  tissue,  which  are  exquisitely  pain- 
ful. These  may  follow  along  the  lines  of  the  tongue,  thus  giving 
rise  to  deep  fissures,  or  they  may  burrow  into  the  crypts  of  the 
tonsils,  or  form  circular  pits  on  the  posterior  wall  of  the  pharynx. 
Not  only  are  fissures  formed  in  the  tongue,  but  they  may  make  their 
appearance  at  the  corners  of  the  mouth  or  the  centers  of  the  lips. 

An  acute  glossitis  or  inflammation  of  the  tongue  is  not  infre- 


SYPHILIS    OF   THE    MOUTH    AND   TONGUE.  26/ 

quently  the  result  of  syphilitic  infection.  There  may  be  first  an 
hypertrophy  of  the  organ,  with  subsequent  contraction,  thus  caus- 
ing deep  transverse  or  longitudinal  furrows.  There  may  be  an 
indurative  or  hardening  change  in  the  muscular  fibers,  with  a 
consequent  partial  loss  of  function,  the  speech  becoming  thickened 
and  indistinct.  Along  the  borders  of  the  tongue  dry  or  squamous 
lesions  sometimes  may  be  seen.  They  are  not  moistened  by  the 
usual  secretions  of  the  mouth,  and  in  color  are  of  a  grayish  or 
bluish  white,  sometimes  having  a  glistening  appearance.  These 
patches  are  specially  marked  among  users  of  tobacco,  particularly 
those  who  are  smokers,  and  there  is  a  distinct  variety  that  has  been 
called  "smoker's  patches."  They  are  not  by  any  means  confified 
to  the  borders  of  the  tongue,  or  even  io  the  tongue  itself,  but 
may  appear  anywhere  in  the  oral  cavity. 

Gummata  of  the  mouth  may  develop  during  the  later  stages  of 
syphilis.  There  may  be  a  compounding  of  these  infiltrations  in 
the  sub-mucous  tissue  of  the  dorsum  of  the  tongue,  causing  as 
many  elevations  and  giving  the  characteristic  "toad's  back"  ap- 
pearance. (See  Fig.  88.)  Their  initial  appearance  is  as  nodules 
beneath  the  mucous  membrane,  from  the  size  of  a  pin's  head  to 
that  of  the  end  of  the  finger,  usually  single,  but  sometimes  multi- 
ple. After  a  time  they  break  down  into  ragged  ulcers,  and  their 
degeneration  is  usually  rapid.  Perhaps  one  appears  in  or  near 
the  center  of  the  vault,  and  when  it  breaks  down  a  probe  will 
detect  necrosed  bone,  which  is  soon  exfoliated,  thus  causing  a 
perforation  of  the  hard  palate. 

The  syphilides  of  the  mouth  assume  a  variety  of  forms,  and 
sometimes  their  diagnosis  is  impossible,  except  with  the  aid  of 
the  clinical  history  of  the  syphilitic  infection.  They  may  possibly 
be  mistaken  for  other  afifections.  The  roseola  may  be  con- 
founded with  a  follicular  stomatitis,  and  the  ulcers  with  cancrum 
oris,  or  noma.  Epitheliomata  may  be  almost  indistinguishable 
from  some  of  the  syphilitic  lesions,  though  ordinarily  they  are  much 
slower  in  their  progress.  Mercurialization  may  usually  be  distin- 
guished from  syphilitic  disturbances  by  the  fetor  of  the  breath,  and 
by  the  distinct  metallic  taste.  But  there  may  be  innocent  ulcera- 
tions upon  the  tongue  or  oral  tissues,  which  the  inexperienced 
syphilologist  might  mistake  if  he  were  to  depend  upon  their 
appearance  alone.     The  only  safe  course  is  to  group  the  various 


268  bRAL   PATHOLOGY   AND    PRACTICE, 

symptoms,  examine  for  glandular  indurations,  and  carefully  and 
delicately  inquire  into  the  history  of  the  case  when  suspicious 
appearances  are  observed  in  the  mouth,  all  the  time  observing 
caution  to  guard  against  possible  infection,  for  if  there  happens  to 
be,  as  is  frequently  the  case,  any  abraded  or  wounded  point  in  the 
fingers,  it  is  possible  for  syphilitic  inoculation  to  take  pla:e  from  a 
secreting  mouth-plaque. 


CHAPTER    LVIII. 
PHYSICAL  DIAGNOSIS. 


The  oral  physician  should  be  competent  to  make  a  proper 
examination  of  a  patient,  for  the  purpose  of  ascertaining  the  ability 
to  withstand  an  operation,  to  take  an  anesthetic,  or  to  determine 
the  probability  of  constitutional  complications.  When  the  regular 
physician  approaches  the  bedside  of  a  sick  person  for  the 
purpose  of  making  a  diagnosis  he  first  takes  the  pulse,  that  he  may 
determine  the  condition  of  the  circulation.  He  next  looks  at  the 
oral  tissues,  especially  the  tongue,  because  upon  it  he  will  find 
reflected  any  disturbance  of  the  digestive  tract.  When  he  has 
learned  to  read  these  aright  he  has  the  key  to  the  state  of  the  two 
most  important  functions  of  the  body,  upon  which,  more  than  any 
others,  health  depends. 

To  be  able  correctly  to  interpret  the  utterances  of  the  pulse, 
of  the  breathing,  or  the  appearance  of  the  oral  tissues,  it  is  essential 
that  the  physician  know  the  language  in  which  they  speak. 
The  technically  uninstructed  man  may  feel  the  pulse,  but  to  him  it 
tells  nothing  except  that  the  heart  is  beating  more  or  less  regu- 
larly. The  accomplished  physical  diagnostician  with  his  eyes  shut 
will  at  once  pronounce  whether  the  patient  is  strong  or  weak;  is 
nervously  excited  or  depressed;  is  in  a  fever  or  rigor;  whether 
the  disturbance  is  functional  or  organic;  whether  in  the  brain  or 
extremities;  whether  there  is  or  is  not  narcotic  or  other  poison- 
ing, with  many  other  matters  that  it  is  essential  to  know. 

The  principal  methods  for  determining  the  state  of  the  internal 
viscera  in  physical  diagnosis  are  auscultation  and  percussion. 

Auscultation  is  the  determination  of  the  condition  by  listening  to 


PHYSICAL    DJAGNOSIS.  269 

the  sounds  which  are  produced  in  normal  or  diseased  functions.  It  is 
called  immediate  when  the  ear  is  applied  directly  to  the  part,  and 
mediate  when  a  stethoscope  or  other  instrument  for  conducting  the 
sound  is  employed. 

Percussion  is  the  striking  lightly  upon  any  part  of  the  body, 
especially  the  thorax  or  abdomen,  zuith  the  vieu)  of  determining  diseased 
conditions  by  the  resonance  or  lack  of  resonance  of  the  sound.  It  is 
called  immediate  when  made  direct  with  the  fingers,  and  mediate 
when  a  pleximeter  or  some  instrument  is  used  to  increase  the 
sound.  Usually  immediate  percussion  is  employed  by  laying  the 
first  two  fingers  of  the  left  hand  upon  the  part,  and  striking  them 
with  the  ends  of  the  first  two  fingers  of  the  right  hand. 

Perhaps  the  dentist  may  not  need  to  become  an  expert,  but 
he  should  at  least  know  the  most  important  expressions  of  the 
heart,  the  lungs,  and  the  digestive  tract,  as  expressed  in  the  pulse, 
the  breathing,  and  the  oral  tissues. 

The  Pulse. 

The  Pulse  is  the  change  in  the  shape  and  size  of  an  artery  due 
to  a  temporary  increase  in  the  tension  of  its  walls  following  a  con- 
traction of  the  heart.  The  muscular  constriction  of  that  organ 
forces  the  blood  out  of  its  ventricles  and  drives  it  through  the 
arteries.  The  coats  of  these  vessels  are  more  or  less  elastic, 
according  to  their  condition,  and  yield  to  the  impulse,  and  if  the 
finger  is  placed  over  an  artery  which  lies  near  the  surface  a  wave 
of  the  sanguinary  fluid  may  be  felt  with  each  contraction  as  it  is 
propelled  from  the  heart  forward.  Of  course,  the  nearer  the 
central  organ  the  more  plainly  perceptible  is  the  impulse,  while 
its  character  will  vary  with  the  resilience  of  the  arterial  coats. 

To  he  able  to  recognize  the  pulse  in  disease,  it  is  necessary  to 
know  what  it  is  in  health.  It  varies  in  different  individuals,  and 
changes  with  their  condition.  It  is  not  the  same  during  growth  as 
in  maturity,  and  every  physical  state  has  its  appropriate  expres- 
sion. There  is  a  difference  of  five  to  six  beats  per  minute  between 
the  pulses  of  men  and  women  of  relatively  the  same  general  physi- 
cal condition  otherwise.  A  difference  of  from  five  to  ten  beats  is 
made  by  change  of  posture  from  the  recumbent  to  the  erect.  By 
violent  running,  or  any  excessive  exercise,  the  rate  may  be  doubled. 
It  is  higher  in  infant  than  in  adult  life,  and  it  decreases  yet  more 
in  old  age. 


Q.'JO  ORAL    PATHOLOGY    AND    PRACTICE. 

The  pulse  may  be  felt  at  any  accessible  artery,  the  larger  and 
nearer  the  heart  the  more  distinctly.  It  is  usually  examined  at 
the  point  of  nearest  exposure  of  the  radial  artery,  in  the 
wrist,  but  dentists  should  be  able  to  read  the  pulsation  of  the  facial 
artery,  where  it  crosses  the  inferior  maxilla,  because  it  is  more 
convenient,  especially  in  the  administration  of  anesthetics.  It  may 
^Iso  be  taken  from  the  carotid  artery  in  the  neck,  or  the  temporal 
beneath  the  ear. 

If  the  pulse  is  taken  at  the  radial  artery  the  tips  of  the  first 
two  fingers  should  be  used,  with  the  second  finger  nearest  the  heart. 
The  strength  is  determined  by  pressing-  with  the  second  finger  until 
the  pulse  cannot  be  felt  with  the  first,  and  taking  note  of  the  amount 
of  force  required  to  compress  the  artery.  The  number  of  pulsa- 
tions are  computed  by  counting.  The  pulse  should  never  be  taken 
when  the  patient  is  in  any  state  of  excitement,  because  its  true 
reading  cannot  be  obtained  at  that  time.  When  first  placed  in  the 
chair,  or  if  a  view  of  the  instruments  is  obtained,  the  pulse  may  be 
raised  several  beats,  and  will  be  changed  in  its  character.  The  best 
time  will  be  after  the  patient  has  entered  the  office  and  sat  for  a 
few  moments,  until  all  nervous  excitement  shall  have  passed  away. 
Then,  in  the  midst  of  conversation  and  without  intermitting  it,  the 
hand  may  be  taken  and  the  pulse  examined.  Of  course,  no  alarm- 
ing display  of  instruments  or  apparatus  will  be  permitted. 

At  birth  the  average  pulsations  are  from  a  hundred  and  twenty 
to  one  hundred  and  forty  per  minute.  The  rate  gradually  dimin- 
ishes until  at  seven  or  eight  years  it  is  about  ninety.  In  adult  life  it 
is  from  sixty-five  to  seventy-five,  while  in  old  age  it  sinks  to  sixty. 
.Some  people  have  normally  a  very  slow  pulse,  while  others  have 
one  that  is  rapid;  hence  it  is  essential  to  have  some  knowledge  of 
what  is  the  normal, rate.  But  an  experienced  physician  will  tell  by 
its  reading  whether  the  slow  or  fast  pulse  is  the  result  of  some  dis- 
turbing influence,  or  whether  it  is  normal.  By  the  use  of  the 
sphygmograph,  an  instrument  devised  for  that  purpose,  he  may 
■obtain  a  permanent  tracing  of  the  pulse  and  all  the  variations  in  the 
blood  pressure,  recorded  through  the  elasticity  of  the  arterial  coats. 
(See  Figs.  93  and  94.) 

In  disease  the  pulse  presents  certain  modifications  that  depend 
upon  the  kind  of  disturbance.  In  the  principal  changes  certain 
■definitions  are  given  which  are  definite  in  their  meaning.     For 


PHYSICAL    DIAGNOSIS. 


271 


instance,  there  is  a  marked  difference  between  a  rapid,  a  quick,  and 
a  frequent  pulse,  and  each  conveys  its  own  tale.  The  principal 
modifications  are  as  follows: 

A  frequent  pulse  means  one  that  is  diuiinishcd  in  force,  hut 
increased  in  frequency.  It  is  the  result  of  and  indicates  debility. 
Thus  before  death  it  may  be  so  frequent  as  almost  to  be  beyond 
counting,  and  so  weak  as  to  be  almost  indistinguishable.  The 
muscle  of  the  heart  is  losing  its  contractile  force. 

Fig.  93. 


Sphygmographic  Tracings  of  the  Pulse  from  the  Radial  Artery  in  a  Healthy 
Man,  Aged  Twenty-five.    (Chapman.) 


Fig.  94. 


Sphygmographic  Tracing  of  the  Pulse,  showing  Low  Tension,  with  Irregularity, 
IN  A  Case  of  Mitral  Regurgitation.    (Mus.ser.) 

A  quick  pulse  is  abrupt,  jerking,  and  may  he  moderate  or  frequent 
in  its  rate  of  pvdsation.  It  indicates  some  irritable  state  of  the  heart, 
■\^•hich  may  be  of  only  a  temporary  nature. 

The  slow  pulse  (unnaturally  so)  occurs  in  narcotic  poisoning  and 
in  apoplexy.  It  will  be  found  in  compressions  of  the  brain  from 
accident,  and  in  unconsciousness  from  opium  or  liquor.  This 
characteristic  enables  the  physician  to  determine  malingering,  and 
the  simulation  of  unconsciousness.  Another  method  to  detect 
counterfeiting  is  to  press  the  end  of  the  thumb  with  considerable 
force  on  the  supra-orbital  foramen  for  one  or  two  minutes,  gradu- 
ally increasing  it.     No  conscious  person  can  long  withstand  this. 

The  hard  pidse  seems  to  indent  the  finger,  and  is  ivhat  the  name 
indicates.  It  shows  great  excitement  of  the  circulation,  with  high 
tension  and  rigidity. 


272  ORAL    PATHOLOGY    AND   PRACTICE. 

The  soft  pulse  is  the  direct  opposite  of  this,  and  indicates  lassitude. 
It  is  easily  compressed,  though  it  may  not  be  readily  extinguished. 

The  febrile  pidse  is  an  increase  in  the  rate  of  pidsation,  and 
usually  of  force  also.  It  is  found  in  active  fevers  and  inflamma- 
tions of  an  acute  character. 

The  feeble  pulse  is  nearly  synonymous  zvith  the  soft  pulse,  but  is 
more  easily  extinguished.  It  is  indicative  of  great  debility  and 
exhaustion. 

llie  thready  pulse  is  one  that  gives  beneath  the  finger  the  sensation 
of  a  vibrating  thread.  It  is  allied  to  the  luiry  pulse,  which  is  an 
exaggerated  condition.  Both  are  sometimes  present  in  very  great 
debility. 

The  irritable  pidse  is  one  that  is  both  frequent  and  hard.  It  will 
be  found  when  a  debilitated  person  is  subjected  to  some  kind  of 
excitement. 

The  intermittent  pulse  is  one  that  nozu  and  then  loses  a  beat.  It  is 
indicative  of  either  functional  or  organic  disease  of  the  heart.  It 
should  not  be  confounded  with  the  weakened  pulsations  of  exhaus- 
tion. 

The  irregular  pulse  is  one  that  varies  in  both  frequency  and  force. 
It  may  be  very  slight,  or  it  may  be  extreme.  It  is  generally  found 
in  heart  disease,  but  it  may  be  the  result  of  the  use  of  tobacco  or 
strong  cofifee  or  tea.  The  inordinate  use  of  stimulants  may  also 
produce  an  irregular  pulse. 

In  reading  the  pulse,  for  instance  to  determine  the  ability  of 
a  person  to  withstand  the  effects  of  an  anesthetic,  the  practitioner 
must  first  be  sure  that  the  patient  is  not  laboring  under  the  ex- 
citement of  fear  or  apprehension.  The  mind  should  be  diverted 
until  the  pulse  is  normal,  when  the  hand  may  be  quietly  taken. 
The  first  thing  will  be  to  determine  the  frequency,  to  learn  if 
there  is  any  functional  excitement.  If  so,  due  allowance  must  be 
made.  Then  its  regularity  should  be  observed,  to  discover  it 
there  is  any  organic  trouble.  After  this  its  force  may  be  ob- 
served, to  ascertain  if  the  heart  is  strong  enough  to  withstand 
the  shock  that  must  be  produced  by  the  anesthetic  agent  or  the 
contemplated  operation;  and  finally  the  condition  of  the  pulse 
should  be  carefully  noted,  to  know  if  there  is  any  functional  irri- 
tation which  would  be  indicated  by  the  "quick,"  "febrile"  or  "irri- 
table" pulse. 


PHYSICAL   DIAGNOSIS.  273 

The  practitioner  should  lose  no  good  opportunity  for  the  study 
of  the  pulse,  both  in  health  and  disease.  He  will  find  that  his 
comprehension  of  it  and  his  ability  to  detect  variations  will  greatly 
increase  with  practice.  He  must  learn  to  read  it  as  he  would 
Greek,  by  first  conquering  its  alphabet,  and  then  slowly  and 
patiently  acquiring  the  combinations.  He  will  discover  that  he 
can  acquire  real  skill  and  facility  in  reading  the  one  about  as  easily 
as  the  other. 

It  should  be  comprehended  that  all  these  modifications  are  not 
produced  simply  through  changes  in  the  force  exerted  by  the  heart 
in  its  pulsations.  The  readings  depend  upon  the  condition  of  the 
coats  of  the  arteries  quite  as  much.  Their  resilience,  or  elasticity, 
is  governed  by  the  vaso-motor  nerves,  and  hence  any  nervous 
shock  or  neural  depression  will  be  readily  manifested  in  the  arterial 
walls,  in  the  manner  indicated  in  the  section  on  Inflammation. 
Thus  the  "hard"  pulse  and  the  "soft"  pulse  will  mainly  depend 
upon  the  tension  of  the  muscular  arterial  coats,  while  the  "slow" 
pulse  and  the  "frequent"  pulse  will  be  the  result  of  the  condition  of 
the  heart,  or  the  rate  of  its  pulsations. 

A  "feeble"  pulse  indicates  that  the  force  of  the  heart-beats  is 
lessened,  and  at  the  same  time  the  tension  and  resiliency  of  the 
arteries  themselves  are  reduced.  The  "soft"  pulse,  on  the  con- 
trary, simply  implies  a  change  in  the  coats  of  the  vessels,  wdthout 
any  special  heart  complications. 

The  "hard,"  or  "wiry,"  or  "thready"  pulse  shows  an  undue 
tension  of  the  arterial  coats,  and  this  will  be  induced  through  some 
nervous  impression  acting  through  the  vaso-motor  system. 

It  may  thus  be  seen  that  the  pulse  gives  a  very  clear  indication 
of  the  state  of  the  nervous  system,  and  reveals  any  neural  shock  or 
depression;  and  that  at  the  same  time  it  is  indicative  of  the  state  of 
the  blood  column  and  of  the  functional  activity  or  languor  of  the 
heart. 


CHAPTER    LIX.  • 
PHYSICAL  DIAGNOSIS  (Continued). 
The  Respiration. 
This  is  the  inspiration   and   expiration   of   air  through  the 
lungs.    By  means  of  the  first  the  blood  is  oxygenated,  while  by  the 

19 


274  ORAL   PATHOLOGY   AND   PRACTICE. 

last  it  is  relieved  of  the  effete  products  of  vital  action.  This  must 
continue  as  long  as  life  lasts.  The  various  sounds  made  in  breath- 
ing, as  well  as  those  of  the  heart,  may  be  determined  by  the  use 
of  the  stethoscope,  or  by  placing-  the  ear  to  the  chest,  not  more 
than  one  thickness  of  cloth  intervening. 

The  breathing  is  termed  either  abdominal  or  thoracic.  That 
is,  the  muscles  chiefly  used  may  be  the  diaphragm,  or  the  costal  and 
superior  thoracic.  The  breathing  in  man  is  mainly  abdominal, 
while  in  woman  it  is  thoracic.  "  In  forced  and  labored  respiration 
yet  other  muscles  may  be  brought  into  action,  as  the  trapezius, 
serratus  magnus,  and  the  sterno-cleido-mastoid. 

In  health,  the  respiration  is  from  thirteen  to  twenty-five  per 
minute.  In  the  dyspnea  of  pneumonia  it  may  rise  to  from  thirty  to 
fifty  per  minute. 

The  normal  respiration  should  be  without  effort,  deep,  and 
unhurried.  There  should  be  no  unusual  noises  or  rales,  and  the 
natural  murmurs  of  the  passage  of  air  through  the  bronchial  tubes 
should  be  present  when  the  ear  is  placed  to  the  chest. 

The  amount  of  air  respired  by  each  individual  is  about  five 
hundred  cubic  centimeters,  and,  of  course,  the  same  amount  is 
exhaled.  But  it  should  not  be  understood  that  all  the  air  is 
expired  at  any  one  time.  After  the  fullest  expiration  there  will 
still  be  left  in  the  lungs  fifteen  to  eighteen  hundred  cubic  centi- 
meters. In  forced  expiration,  or  exhaustion,  most  of  this  air  may 
be  forced  out. 

The  purification  of  the  blood  is  through  the  process  of  respira- 
tion. Oxygen  is  taken  in,  and  carbon  dioxid,  water,  and  various 
organic  matter  are  exhaled.  A  great  deal  of  efifete  matter  is 
eliminated  from  the  pulmonary  surfaces.  In  the  administration  of 
anesthetics  they  are  usually  taken  into  the  lungs  by  inhaling  their 
vapor,  and  thence  pass  directly  into  the  blood;  in  their  elimina- 
tion it  is  chiefly  the  lungs  which  throw  them  off.  They  circulate 
with  the  blood  until  they  again  reach  the  pulmonary  surfaces,  when 
they  are  given  up.  Hence,  in  the  recovery  from  the  anesthetic 
state,  it  is  of  the  first  importance  that  the  breathing  be  maintained 
evenly  and  regularly,  as  otherwise  the  poison  remains  in  the 
system. 

In  diseased  conditions  the  respiration  may  be  either  faster  or 
slower  than  the  normal.     When  it  is  very  much  accelerated  it  will 


PHYSICAL   DIAGNOSIS.  275 

probably  be  superficial,  shallow,  and  gasping.  This  will  be  the 
case  when  it  is  above  thirty-five,  in  pneumonia,  pleurisy,  obstruc- 
tions in  the  trachea,  or  any  kind  of  dyspnea. 

It  will  be  retarded  and  will  be  deep  in  narcotic  poisoning  and 
in  cerebral  compressions,  falling  as  low  as  twelve  to  the  minute. 

When  the  lung  is  filling  up,  becoming  consolidated,  it  will  be 
interrupted,  broken,  and  irregular. 

Bronchial  breathing  will  be  marked  by  blowing,  as  through  a 
tube,  and  it  will  have  a  high  pitch.  This  will  be  the  case  in 
advanced  phthisis,  in  exudations,  hemorrhages  of  the  lungs,  etc. 

The  normal  sounds  that  are  heard  when  the  air  rushes  through 
the  various  passages  are  called  "respiratory  murmurs."  In  health 
these  should  be  smooth,  regular,  easy,  and  without  interruptions. 
All  the  involuntary  muscles  of  respiration  should  work  without 
effort,  and  the  expansion  and  contraction  of  the  thorax  should 
be  uniform  and  regularly  periodical.  The  practitioner  should 
carefully  observe  these  particulars  before  attempting  a  closer 
examination,  and  without  allowing  the  attention  of  the  patient 
to  be  called  to  it,  that  he  may  learn  what  is  the  usual  rate,  for 
the  frec[uency  and  effort  may  be  increased  by  the  nervous  irrita- 
tion attending  auscultation. 

In  diseased  conditions  the  respiratory  murmurs  may  be  ma- 
terially changed.  The  breathing  may  be  labored  and  difficult, 
through  partial  closure  of  the  respiratory  passages  by  inflam- 
matory action,  through  stoppage  by  fluid  exudations,  or  by  nervous 
constrictions. 

The  bubbling  sound  that  is  produced  will  be  either  coarse  or 
fine.  The  coarser  it  is  the  higher  up  it  will  be,  and  the  weaker 
will  be  the  patient.  It  means  the  presence  of  water  and  moisture 
in  excess  in  the  air  passages.  These  air  tubes  must  always  be 
properly  lubricated,  but  when  through  some  pathological  condi- 
tion moisture  accumulates  in  inordinate  quantities,  it  impedes  or 
even  wholly  stops  the  passage  of  the  air.  In  the  latter  case  the 
patient  may  absolutely  be  drowned  in  his  own  effusions. 

Gurgling,  like  zvater  boiling,  may  he  heard  in  pulmonary  cavities 
at  times,  and  indicates  an  advanced  state  of  phthisis. 

Splashing  sounds  upon  succussion,  or  shaking  or  striking  the 
chest,  in  the  pleural  organ  indicate  hydro-  or  pyo-pneumothorax — water 
or  pus,  zvith  air,  in  the  pleural  cavity. 


2/6  ORAL    PATHOLOGY    AND    PRACTICE. 

Loud  zvhistling  or  zvheezing  that  may  he  heard  at  a  distance  in 
the  larynx  or  trachea  indicates  stenosis,  or  constriction,  and  is  heard 
in  croup. 

Low-pitched  snoring  in  the  larger  bronchi  means  spasms,  or  nar- 
rowing of  the  bronchi,  as  in  asthma. 

A  crackling  sound  located  in  the  air  vessels  of  the  lungs  shows  a 
sticking  of  their  walls,  and  is  heard  in  pneumonia. 

Creaking,  grazing  sounds  are  heard  in  pleurisy,  and  indicate 
exudations  upon  the  surfaces  of  the  pleura. 

Metallic,  tinkling  sounds  in  pleural  or  pulmonary  cavities  mean 
pneumothorax,  or  the  escape  of  air  into  some  cavity. 

The  abnormal  sounds  produced  when  the  air  breaks  through 
impediments  or  passes  over  obstructions  in  the  lungs,  bronchi  or 
trachea,  are  called  rales  (French  raler,  to  rattle),  and  are  said  to  be 
either  moist  or  dry. 

Dry  rales  ivill  usually  be  induced  by  a  condition  of  the  air  passages 
in  which  they  are  not  lubricated  zvith  the  normal  mucous  secretion,  or 
zvhen  it  is  inspissated  or  thickened;  hence  they  are  usually  of  a  crack- 
ling or  whistling  character. 

Moist  rales  are  produced  zvhen  the  obstruction  is  fluid,  and  are 
apt  to  be  of  a  bubbling  nature.  Peculiar  conditions  may,  hozvever, 
modify  either  of  these,  and  special  pidmonary  diseases  have  their  ozvn 
specific  rales. 

Cavernous  rales  are  observed  when  there  is  a  cavity  filled  zvith 
pus. 

Crepitant  rales  are  the  crackling  sounds  symptomatic  of  the  first 
stage  of  pneumonia. 

Mucous  rales  are  the  bubbling  sounds  produced  by  the  passage 
of  air  through  bronchial  mucus. 

Sibilant  rales  are  those  that  have  a  sharp,  hissing  sound,  as  zvhen 
air  passes  through  a  contracted  moist  passage,  or  through  foaming 
fluids. 

Sonorous  rales  are  the  stertorous,  snoring  sounds,  as  if  the  air 
zvere  interrupted  by  some  vibrating  substance. 

Friction  rales  are  the  creaking  sounds  heard  when,  zvithout  the 
lubricating  fluid  that  is  natural  to  them,  two  surfaces  rub  upon  each 
other. 

Vesicular  rales  arc  the  fine  crepitant  sounds  heard  in  the  vesicles 
of  the  limgs  in  the  early  stages  of  inflammation. 


PHYSICAL   DIAGNOSIS.  ^JJ 

Siibcrepitant,  or  tracheal,  rales  are  heard  when  mucus  accumu- 
lates in  the  larger  bronchi,  or  the  trachea,  and  they  form  what  is  called 
the  "death  rattle."    It  is  usually  a  prenianitory  symptom  of  dissolution. 

There  are  other  murmurs  heard  in  auscultation  than  those 
produced  by  the  air  in  inspiration  and  expiration.  They  are  caused 
by  the  movements  of  the  blood  current  in  the  vessels,  and  by  the 
friction  produced  by  gliding  surfaces  in  the  organs  of  respiration 
and  circulation.  Sometimes  the  French  term  "bruit,"  having  the 
same  signification,  is  applied  to  them. 

The  arterial  murmur  is  the  sound  made  by  the  arterial  current, 
and  it  may  be  normal  or  disturbed. 

The  cardiac  murmur  is  the  union  of  the  systolic  (contracting) 
and  diastolic  (dilating)  sounds  produced  by  the  muscidar  actions  of 
the  heart  and  the  passage  of  the  blood  through  its  auricles,  ventricles, 
and  valves. 

Hemic  murmurs  are  the  sounds  due  to  changes  in  the  quality  and 
amount  of  the  blood  itself,  and  not  to  modifications  in  the  vessels  or 
valves. 

The  venous  murmurs  are  the  so-called  "bruit  dc  diable"  of  the 
French,  produced  in  the  common  jugular  in  anemia,  lead-poisoning,  etc. 

Artificial  Respiration. 

The  dentist  will  not  infrequently  be  called  upon  to  use  artificial 
respiration,  and  a  few  plain,  uncomplicated  directions  are  necessary. 
Many  persons  each  year  are  lost  whose  lives  might  readily  enough 
be  saved  if  this  subject  was  better  understood.  No  one  should  be 
pronounced  dead  as  long  as  there  is  the  very  slightest  flutter  of  the 
heart,  or  when  there  is  any  vital  warmth  present.  People  have 
been  restored  after  hours  of  unremitting  efforts,  unrewarded  by 
even  a  gasp  until  near  the  end.  Artificial  respiration  has  held 
death  at  bay  for  days  before  any  voluntary  efforts  could  be  induced. 

In  cases  of  cessation  of  breathing  not  an  instant  should  be  lost 
in  getting  the  patient  into  a  prone  or  recumbent  position,  if  he  is 
not  already  so  placed.  All  clothing  should  be  loosened  and  the 
tongue  seized  with  a  pair  of  forceps,  or  a  tenaculum,  and  forcibly 
drawn  forward,  at  the  same  time  raising  the  head  a  little  to  insure 
the  opening  of  the  glottis.  In  the  absence  of  any  such  instrument 
any  other  suitable  object  may  be  thrust  in  the  mouth  and  the 
base  of  the  tongue  pressed  down  and  forward  with  it.    Something 


278  ORAL    PATHOLOGY   AND   PRACTICE. 

should  then  be  placed  under  the  patient's  shoulders  to  raise  the 
chest.  The  coat  of  the  operator  is  excellent,  if  nothing  else  is  at 
hand. 

The  most  simple  and  easily  comprehensible  method  of  pro- 
ducing artificial  respiration  is  that  called  "Sylvester's,"  and  either 
this  or  some  other  that  is  equally  effective  should  be  at  once 
employed.  The  operator  will  place  himself  at  the  head  of  the 
unconscious  person  and  seize  the  wrists.  Then  by  a  sweeping 
motion  the  arms  should  be  extended,  and  at  the  same  time  hori- 
zontally carried  to  their  fullest  extent  above  the  head.  After  an 
instant's  interval  they  should  be  carried  back  by  reversing  the 
motion  until  they  rest  across  the  body  just  below  the  diaphragm, 
when  firm  pressure  upward  and  against  the  body  should  be  exerted. 
These  motions  should  be  continued  about  fifteen  times  per  minute 
for  an  indefinite  time,  at  the  same  time  keeping  up  the  bodily  heat 
by  the  use  of  hot-water  bottles,  hot  flannels,  and  chafing  of  the 
extremities. 

In  cases  of  drowning,  or  the  presence  of  fluid  in  the  air 
passages,  the  body  should  first  be  held  with  the  head  down  and 
the  epiglottis  be  kept  open  to  expel  the  water.  Violent  rolling 
upon  a  barrel  or  like  object  should  never  be  practiced,  as  the 
shock  may  extinguish  the  lingering  spark  of  life.  Water  will 
always  run  down  hill  if  its  course  is  unimpeded.  It  is  well  in 
such  instances  occasionally  to  interrupt  the  artificial  respiration 
momentarily,  turn  the  body  on  the  side  and  depress  the  head,  to 
allow  the  escape  of  any  fluid  that  may  have  been  expelled  from 
the  air  passages. 

When  there  is  sinking  after  the  giving  of  an  anesthetic,  or  in 
cocain  or  opium  poisoning,  artificial  respiration  may  be  necessary; 
but  if  breathing  is  once  established  the  patient  should  be  exercised 
as  violently  as  practicable  to  assist  the  circulation  and  to  aid  in 
the  elimination  of  the  drug.  A  hypodermic  injection  of  brandy 
may  be  administered,  or  one  of  ammonia.  Strong  cofifee  is  an 
excellent  antidote,  as  is  any  stimulant.  Cocain  poisoning  will  be 
manifested  by  symptoms  very  like  those  due  to  opium.  People  do 
not  die  of  cocain  poisoning  except  after  the  lapse  of  some  time, 
as  in  poisoning  from  opium,  and  the  narcotic  effects  are  plainly 
visible  before  death  ensues.  The  instances  in  which  it  is  related 
that  death  occurred  within  a  few  moments  after  the  injection  of  a 


THE   ORAL   TISSUES    IN    DIAGNOSIS.  279 

cocain  solution  were  doubtless  errors  of  diagnosis.     The  patient 
probably  died  of  something-  else  than  narcotic  poisoning. 


CHAPTER     LX. 
THE  ORAL  TISSUES  IN  DIAGNOSIS. 

All  gastric  disturbances  are  reflected  in  the  tissues  of  the 
mouth.  The  tongue  especially  is  very  expressive,  and  the  oral 
physician  or  dentist  should  learn  to  read  its  indications  as  he  would 
an  open  book. 

In  health,  the  tongue  is  of  a  delicate  whitish  pink  color,  smooth 
and  moist.  Any  departure  from  this  appearance,  either  in  the 
tongue  or  the  other  oral  tissues,  means  a  pathological  state  that 
demands  the  attention  of  a  doctor.  In  another  chapter,  local 
inflammations  with  their  symptoms  have  been  described,  and  it 
remains  but  to  give  the  appearance  in  general  functional  dis- 
turbances. 

The  tongue  is  at  times  covered  with  a  coating  called  "fur."^ 
This  always  indicates  defective  circulation  of  some  kind.  Fur 
consists  of  the  unremoved  epithelia  of  the  mucous  membrane, 
of  the  thickened,  inspissated  mucus,  of  the  debris  of  food,  or 
of  some  deposit.  In  pathological  conditions  the  furring  of  the 
tongue  is  by  regular  gradations,  commencing  at  the  base  and 
spreading  toward  the  tip.  In  clearing  up  this  is  reversed,  the 
clean  spots  first  appearing  at  the  end  and  sides,  and  spreading 
toward  the  base,  so  that  by  watching  the  progression  or  retrogres- 
sion of  this  process  a  fair  knowledge  of  the  progress  of  the  disease 
may  be  obtained. 

Generally  speaking,  a  dull  whitish  color  of  the  tongue  indicates 
a  hyperacid  condition;  while  red,  with  fur,  points  to  an  alkaline  or 
inflammatory  state. 

A  delicate  whitish  tint  of  the  tongue  within  two  hours  after  eating 
means  that  digestion  is  not  completed.  This  tint  should  not  be  con- 
founded with  disease  indications.  If  the  tint  remains  for  more 
than  four  hours  it  means  arrested  digestion. 

White,  with  a  thin  coating,  means  acidity.  A  yellowish  white^ 
acidity  with   biliary  irritation.    A   very  white  and   thick   coating 


280  ORAL   PATHOLOGY   AND    PRACTICE. 

("flannel  mouth")  means  intense  venous  congestion,  as  in  cerebrospinal 
meningitis. 

Red,  a  delicate  pinkish  tinge,  indicates  that  digestion  is  completed. 

Red  of  a  deeper  hue  means  arterial  congestion. 

Red,  a  very  deep  and  dark  tinge,  means  the  last  condition  very 
much  exaggerated. 

Red,  bright  in  color  and  raw  or  glazed,  indicates  paralysis  of  the 
sympathetic — approaching  fatal  exhaustion. 

Broivn,  or  brownish  red,  with  a  thick  dry  coating,  means  prostra- 
tion; arterial  congestion;  carbonic  acid  poisoning — a  sign  of  danger. 

Black,  or  blackish,  not  deep,  means  blood  poisoning — -pyemia; 
sepsis. 

Blue,  or  a  bluish  tinge,  indicates  lack  of  oxygen;  cyanosis. 

Humidity  of  the  tongue  means  atony  (lack  of  tone),  zvith  anemia. 

Dryness  means  nervous  irritation;  debility. 

Flabbincss,  fidlness,  trenndousness,  indicate  great  debility. 

Imperfect  muscular  movements,  difUcult  articulation,  means 
cerebrospinal  irritation;  drunkenness. 

There  are  exceptional  conditions  that  are  but  temporary  in 
character  and  not  indicative  of  a  real  pathological  degeneration. 
These  must  not  be  lost  sight  of,  but  must  first  be  eliminated  as 
causes  in  making  a  diagnosis.    The  following  are  instances : 

The  tongue  may  be  furred  in  health,  as  in  excessive  smoking. 

A  dry  tongue  may  be  due  to  fever  or  to  loss  of  sleep,  or  to 
excessive  fatigue. 

In  old  age  the  tongue  loses  its  diagnostic  value  to  a  great 
extent. 

In  scarlet  fever  the  desqiiamatiqn  may  cause  what  is  known  as 
the  "sfrazvberry  tongue."  It  is  generally  accompanied  with  des- 
quamation of  the  kidneys,  etc. 

Depressing  nervous  impressions  may  cause  a  tremulousness 
and  dryness  that  is  but  temporary,  as  in  fright  and  great  anxiety. 

Pleasurable  sensations,  the  sight  of  food,  etc.,  may  induce  a 
temporary  humidity.     "The  mouth  waters." 

It  should  be  understood  that  it  is  not  the  tongue  alone  of  the 
oral  tissues  that  is  indicative  of  the  bodily  state.  Others  may  be 
equally  expressive,  and  the  judicious  diagnostician  will  take  them 
ail  into  account  in  making  up  the  sum  of  the  objective  symptoms. 


THE   ORAL   TISSUES    IN    DIAGXOSIS.  281 

A  red  line,  or  red  blotches,  along  the  gums  at  a  little  distance  from 
the  margin  is  a  diagnostic  sign  of  pericemental  or  periosteal  irritation. 

A  still  deeper  red  color,  with  excessive  Hoiv  of  saliva,  is  found  in 
ptyalism,  or  merciirialisation. 

A  blue  line  along  the  gums  at  the  margin  is  indicative  of  lead 
poisoning. 

Great  sponginess,  sloughing  of  the  gums,  with  fetor,  indicate 
scurvy. 

Dark  red  gums,  piiffiness,  everted  edges,  with  oozing  of  pus,  are 
found  in  pyorrheal  conditions. 

Purple  gums,  zvith  a  purulent  discharge  at  more  than  one  point, 
are  indicative  of  caries  or  necrosis  of  bone. 

Gums  hot  and  swollen,  z'cry  tense,  with  a  determination  toward 
one  point,  mean  suppuration,  alveolar  abscess,  phlegmon. 

Gums  inflamed  and  soft,  with  fluctuation,  indicate  the  pressure  of 
pus,  which  should  be  evacuated. 

SzvoUen  gums,  fetid  discharge,  mucous  patches,  shallow  ulcers 
under  the  tongue,  eruptions  about  the  mouth,  skin,  and  scalp,  gums 
everted,  zvith  fetid  matter  about  the  necks  of  the  teeth,  the  tongue  per- 
haps swollen  and  flabby,  zvith  the  edges  scalloped  by  the  pressure  of 
the  teeth,  may  be  found  in  syphilitic  conditions. 

It  should  be  comprehended  that  not  all  these  symptoms  or 
appearances  will  be  observed  in  one  mouth,  but  any  one  of  them 
should  stimulate  the  dentist  to  further  examination  and  inquiry. 

The  indications  of  imminent  danger  as  presented  by  the  tongue 
are  a  tremulous  action,  dryness,  blueness,  very  red,  shining,  or 
glazed  aspect,  heavy  furring,  dark  or  black  hue — the  so-called 
"black  tongue." 

In  considering  the  tongue  and  the  oral  tissues  as  diagnostic 
organs,  the  indications  are  not  to  be  taken  alone.  The  appearance 
should  always  be  studied  in  connection  with  other  symptoms, 
which  may  be  the  dominant  ones,  and  may  reverse  the  usual  signi- 
fications. The  oral  tissues  are  to  be  considered  as  auxiliary,  and 
not  in  every  case  pathognomonic.  The  diagnosis  is  to  be  reached 
by  grouping  all  together,  and  reading  one  sign  by  the  aid  of  the 
others. 


282  ORAL    PATHOLOGY    AND    PRACTICE. 

CHAPTER    LXI. 

WOUNDS  AND  INJURIES. 

A  wound  is  a  solution  of  continuity  in  the  soft  parts,  suddenly 
produced.  It  is  a  rupture  of  the  tissues  by  some  form  of  mechanical 
violence,  and  may  be  produced  by  a  direct  or  an  indirect  applica- 
tion of  force. 

A  wound  may  be  a  complete  separation,  with  exposure  of  the 
tissues  to  external  influences,  or  it  may  be  a  mere  contusion,  with- 
out any  breaking  of  the  integument. 

Wounds  have  their  own  train  of  symptoms,  which  are  usually 
quite  pronounced,  so  that,  except  in  certain  instances  of  deep- 
seated  injuries,  their  diagnosis  is  comparatively  easy. 

Wounds  are  distinguished  by  pain,  hemorrhage,  loss  of 
function,  shock,  and,  in  injuiies  of  the  head,  concussion. 

The  pain  is  characteristic,  and  is  usually  proportional  to  the 
amount  of  the  injury.  When  the  tissues  are  crushed  and  there  is 
deep  contusion,  the  pain  is  sometimes  very  severe. 

The  hemorrhage  varies  greatly  with  the  vascularity  of  the 
tissue  affected.  All  wounds  must  have  some  hemorrhage,  for  all 
soft  tissues  are  supplied  with  blood.  Even  in  case  of  a  wheal, 
which  is  merely  a  stripe  or  a  ridge  upon  the  skin,  such  as  follows 
the  cut  of  a  whip,  there  is  usually  more  or  less  capillary  bleeding. 

Loss  of  function  differs  with  the  location.  It  may  be  merely 
local  or  it  may  be  general,  varying  with  the  extent  of  the  injury 
and  with  the  tissue  involved.  A  single  small  muscle  may  be  cut, 
as  for  instance  the  extensor  of  one  of  the  digits,  in  which  case  the 
function  of  but  one  finger  would  be  interfered  with;  or  there  may 
be  such  laceration  of  the  muscles  of  the  hand  as  to  inhibit  the 
action  of  all  the  fingers. 

Wounds  are  succeeded  by  traumatic  "shock,"  which  will  be 
proportioned  to  the  resistive  force  of  the  body  at  the  time,  the 
amount  of  injury,  the  location  of  the  lesion,  etc.  The  physical 
condition  of  the  patient  may  be  such  as  to  make  this  very  pro- 
found, or  there  may  be  a  high  condition  of  tonicity  that  will 
minimize  it.  The  lesion  may  be  in  such  vital  organs 
that  the  constitutional  disturbance  will  be  great,  or  while 
considerable    in    extent    the    wound    may    be    in    tissues    that 


WOUNDS    AND    INJURIES.  283, 

react  but  feebly.  The  age  of  the  patient  makes  a  material  differ- 
ence in  the  amount  of  the  consequent  shock,  and  sex  is  an 
important  factor,  women  suffering  from  it  much  less  than  men. 

Wounds  are  incised,  lacerated,  contused,  punctured,  per- 
forating^, gunshot,  or  poisoned. 

An  incised  wound  is  one  made  as  with  a  sharp  instrument.  Its 
diagnosis  is  not  always  as  easy  as  might  be  imagined,  for  a  blow 
with  a  bludgeon  may  cause  an  incised  wound  if  it  be  delivered  over 
a  bone  with  a  sharp  edge,  in  which  instances  the  incision  will  be 
from  beneath,  and  not  from  the  surface;  or  the  impact  of  a  blunt 
instrument  may  be  at  such  an  angle  as  to  produce  a  sharp  rupture 
of  the  tissues, 

A  lacerated  wound  is  one  in  zvhich  the  tissues  are  pulled  apart. 
They  are  torn  and  ragged,  and  it  is  usually  the  result  of  an  injury 
from  compound  causes,  such  as  being  caught  in  complicated 
machinery. 

A  contused  zvoimd  is  one  zvhich  is  made  with  a  blunt  weapon. 
There  is  usually  crushing  of  the  tissues,  without  breaking  of  the 
skin.  In  such  instances  the  connective  tissue,  with  its  inclosed 
vessels,  always  suffers.  If  but  a  few  vessels  are  injured  it  is  com- 
monly called  a  bruise.  The  hemorrhage  consequent  upon  a  con- 
tused wound  is  slight,  and  is  usually  limited  to  mere  ecchymosis, 
or  infiltration  of  blood  into  the  tissues.  The  ordinary  "black  eye" 
is  an  instance  of  this.  The  blood  extravasated  into  the  cellular 
tissue  assumes  the  dark  venous  hue,  changes  to  a  purplish  black, 
then  to  a  brownish  green,  finally  assumes  a  yellow  tint,  and  is 
absorbed. 

A  punctured  wound  is  one  that  is  made  into  a  cavity  of  the  body. 
The  gravity  of  a  punctured  wound  depends  upon  the  cavity  that 
may  be  reached.  Punctured  wounds  of  the  abdominal,  the 
thoracic,  or  the  cranial  cavities  are  usually  of  a  serious  nature, 
owing  to  the  danger  of  infection. 

A  perforating  zvound  goes  entirely  through  an  organ  or  a  tissue. 
The  terms  perforating  and  punctured  are  occasionally  confused, 
some  pathologists  defining  as  punctured  wounds  those  made  by  a 
pointed  instrument,  and  perforating  wounds  those  which  reach  to 
and  open  a  cavity  of  the  body. 

Gunshot  wounds  are  those  made  by  the  discharge  of  fire-arms. 
Works   on   surgery  usually   consider  these   as   a   distinct   class. 


284  ORAL    PATHOLOGY   AND    PRACTICE. 

because  of  the  special  complications  in  which  they  are  apt  to  be 
involved.  Not  infrequently  in  gunshot  wounds  foreign  substances' 
are  carried  in,  such  as  portions  of  the  clothing,  debris  of  the 
explosion,  etc.  Thus  the  danger  of  infection  is  greatly  increased, 
and  the  irritation  produced  is  much  more  violent.  The  impact  of 
bullets,  from  their  great  velocity,  increases  the  probability  of  shock, 
and  at  the  same  time  too  often  disengages  splinters  of  bone,  which 
bring  on  new  complications.  The  rotation  of  the  rifled  bullet  adds 
to  the  amount  of  destruction  of  tissue,  so  that  the  track  left  by  its 
passage,  while  very  difficult  to  follow  with  a  probe  immediately 
after  the  injury,  is  peculiarly  liable  to  be  made  manifest  subse- 
quently, through  the  breaking  down  of  the  tissue. 

A  poisoned  zvound  is  one  that  is  infected  with  some  mineral, 
vegetable,  or  animal  poison.  The  most  common  of  these  are  the 
bites  of  poisonous  reptiles  or  insects,  the  stings  of  bees,  wasps,  etc., 
and  the  effects  produced  by  the  poison  ivy,  oak,  and  other  toxic 
vegetables,  as  well  as  by  bites  of  men  and  animals  and  infections  by 
dirty  tools. 

Wounds  may  be  of  a  septic  or  aseptic  character.  In  the  former 
they  have  become  infected  with  septic  organisms,  amd  there  will  be 
breaking  down  of  tissue  with  suppuration,  or  the  formation  of  pus. 
The  septic  bacteria  are  the  greatest  enemies  the  surgeon  has  to 
encounter  in  the  treatment  of  wounds,  and  hence  his  chief  efforts 
are  directed  toward  the  establishment  of  an  aseptic,  or  sterile  condi- 
tion. 

Wounds  are  healed  by  primary  union,  or,  as  it  is  often  called, 
First  Intention,  by  granulation  or  Second  Intention,  and  by  Third 
Intention.  They  are  united  by  means  of  the  fibrinous  plastic 
exudate  which  is  the  result  of  the  inflammatory  process,  and  which 
earlier  or  later  in  the  progress  of  healing  agglutinates  or  unites  the 
severed  walls. 

Primary  union  or  First  Intention  is  the  healing  without  infec- 
tion. There  is  no  retrograde  metamorphosis,  or  breaking  down 
of  tissue.  There  are  no  acute  symptoms  of  any  kind,  and  no 
granulation  occurs. 

Granulation,  or  Second  Intention,  is  the  healing  of  a  wound  by 
the  regular  progressive  additions  of  papillary  or  grain-like  growths. 
Capillary  loops  form  at  the  bottom  of  the  cavity  of  the  wound, 
and  through  them  new  tissue  is  developed.     Upon  the  summit  of 


TREATMENT   OF    WOUNDS.  285 

these,  new  capillary  loops  appear  and  new  granulative  tissue  is 
formed,  which  follows  the  type  of  that  from  which  it  originated 
or  to  which  it  is  to  be  joined,  and  this  process  is  continued  by 
"healing  from  the  bottom,"  until  the  waste  tissue  is  restored. 
(See  Fig.  12.) 

Third  Intention  is  the  direct  union  of  two  surfaces  on  which 
granulation  has  already  taken  place.  In  fact,  it  does  not  in  essential 
character  differ  from  second  intention,  the  granular  or  capillary 
loops  being  formed  in  the  same  manner,  but  there  is  less  of 
cicatricial  or  scar  tissue  as  tlie  result. 

It  should  be  borne  in  mind  that  this  system  of  nomenclature 
is  rather  arbitrary,  and  in  part  founded  upon  hypotheses  which  are 
not  fully  accepted  by  modern  pathologists.  All  healing  in  one 
sense  is  by  a  kind  of  granulation,  but  as  this  phenomenon  presents 
certain  distinct  phases,  and  as  the  old  system  of  nomenclature  will 
doubtless  be  insisted  on  for  some  time  to  come,  it  has  been  retained 
with  this  explanation. 

When  granulation  becomes  too  exuberant  it  may  continue 
above  the  surface,  and  is  then  commonly  denoted  "proud  flesh." 
Usually,  when  the  capillary  loops  reach  the  level  of  the  surface,  the 
fibrous  exudate  contracts  and  cuts  off  the  blood  supply,  and  the 
process  is  stopped.  There  is  a  proliferation  of  the  epithelial  cells, 
or  a  growth  of  the  investing  tissue  over  it,  and  it  is  thus  covered 
with  the  dermal  appendage,  and  the  process  completed.  But,  as 
has  been  stated,  this  may  not  take  place,  and  in  that  case  the  result 
will  be  a  hyperplasia,  or  excessive  formation.  For  further  study  of 
the  healing  process  the  student  is  referred  to  the  chapters  on  inflam- 
mation. 


CHAPTER    LXII. 
TREATMENT  OF  WOUNDS. 


The  healing  of  a  wound  is  induced  and  incited  by  cleanliness 
and  an  aseptic  condition.  In  treatment  the  first  step,  in  the  case  of 
an  open  wound,  is  to  remove  any  foreign  substances.  Especially 
in  incised,  lacerated,  and  gunshot  wounds  should  careful  examina- 
tion and,  if  necessary,  exploration  be  made,  to  determine  if  any 
extraneous  matter  has  been  carried  in  by  the  instrument  of  injury. 


^86  ORAL    PATHOLOGY   AND    PRACTICE. 

If  this  is  suspected,  the  wound  must  be  carefully  laid  open  to  its 
•extremest  point,  and  thorough  exploration  made.  There  can  be 
no  healing  so  long  as  any  particle  of  irritating  foreign  matter 
remains. 

In  the  case  of  a  lacerated  wound,  the  tissues  should  be  carefully 
examined  to  determine  the  probability  of  the  maintenance  of  the 
vascular  supply  in  them.  If  the  bloodvessels  are  so  thoroughly 
destroyed  that  circulation  will  be  completely  cut  off,  such  injured 
tissue  must  be  removed,  to  obviate  the  dangers  of  gangrene.  They 
cannot  recover  unless  they  are  supplied  with  pabulum,  and  this  is 
carried  by  the  arteries.  Hence,  if  there  is  no  chance  for  the 
restoration  of  circulation  in  the  part,  amputation  or  excision  is 
imperative,  and  should  not  be  delayed. 

The  destruction  of  an  artery  or  vein  does  not  by  any  means 
imply  that  circulation  is  entirely  prevented,  for  it  may  be  carried  on 
through  the  collateral  supply.  It  is  only  when  all,  or  nearly  all, 
the  communicating  tissue  is  so  injured  that  its  vessels  can  no 
longer  convey  a  supply  of  blood  that  its  removal  is  necessarily 
■demanded.  Amputation  of  a  part  has  sometimes  been  resorted 
to  when  the  circulation  might  have  been  maintained,  and  when 
the  vigor  of  the  patient  might  have  promised  continued  functional 
activity. 

The  wound  should  be  irrigated,  and  thoroughly  washed  out 
with  a  disinfecting  and  sterilizing  fluid.  It  is  sometimes  necessary 
to  use  a  great  deal  of  judgment  in  selecting  this.  If  the  injury  is 
very  recent  it  is  not  well  to  use  a  mercuric  chloride  solution, 
because  this  may  induce  mercurial  poisoning.  Nor  should  carbolic 
acid  or  iodine  be  employed,  as  they  may  bring  about  carbolic  or 
iodine  poisoning.  Preparations  of  hydronaphthol,  formalin,  or 
l)oric  acid  are  preferable.  If,  however,  there  is  an  infected  condi- 
tion and  pus  is  present,  the  stronger  germicides,  like  mercuric 
chloride  i  part  to  from  2000  to  4000  parts  of  water,  may  be  em- 
ployed. 

It  is  not  sufficient  if  only  the  interior  of  a  wound  is  cleansed. 
The  tissue  about  it  should  be  carefully  washed  with  an  anti- 
septic fluid,  and  all  foreign  matters  removed.  If  the  edges  are 
surrounded  by  hair,  this  must  be  clipped  or  shaved  off,  that  it 
may  not  harbor  any  impurities,  and  everything  that  might  cause 
irritation  must  be  heedfully  eliminated. 


TREATMiirrr  of  wounds.  287 

No  operations  about  a  wound  are  permissible  without  the  most 
stringent  antiseptic  precautions.  All  the  sponges  and  cloths  used 
must  be  sterilized.  The  hands  of  the  surgeon  must  be  thoroughly 
washed  with  aseptic  soap,  all  matter  under  the  nails  being  removed, 
and  finally  they  must  be  drenched  with  an  antiseptic  mixture,  or 
washed  with  ground  mustard  used  in  place  of  soap. 

A  broad  and  shallow  vessel  partly  filled  with  a  solution  of  car- 
bolic acid,  hydronaphthol,  formalin,  or  some  other  good  anti- 
septic, should  be  provided  for  all  instruments  used,  and  these  must 
frequently  be  dropped  into  it.  Especially  if  any  instrument  or 
sponge  should  happen  to  come  in  contact  with  any  unsterilized 
body,  as  by  an  accidental  dropping  upon  the  floor,  must  it  be  given 
a  bath  in  the  sterilizing  tray. 

If  the  hemorrhage  from  a  wound  is  light  in  color,  or  if  it  issues 
by  distinct  spurts,  it  is  arterial.  If  dark  in  color  and  steady  in  its 
flow  it  is  venous;  if  merely  oozing  it  is  capillary.  Either  may  be 
controlled  by  means  of  the  hemostatic  forceps,  and  by  ligatures. 
Enough  of  the  former  instruments  should  be  kept  in  the  sterilizing 
solution  for  any  emergency.  With  one  of  these  the  mouth  of  a 
bleeding  artery  or  vein  is  seized,  the  handles  are  locked,  and  it  is 
allowed  to  remain  in  position  until  the  close  of  the  operation.  If 
the  bleeding  has  not  then  been  stopped  by  the  contraction  of  the 
muscular  coats,  a  ligature  may  be  passed  about  the  vessel  and  the 
ends  allowed  to  protrude  from  the  wound. 

AVhen  the  bleeding  is  capillary,  it  may  be  necessary  to  pass  a 
ligature  around  a  portion  of  the  tissue  for  the  purpose  of  arresting 
it.  When  it  is  venous,  it  is  sometimes  sufficient  to  seize  the 
mouths  of  the  vessels  with  one  pair  of  artery  forceps,  draw  them 
out  sufficiently  to  allow  of  grasping  them  with  a  second  pair,  and 
then  to  close  them  by  torsion  or  twisting. 

For  controlling  the  hemorrhage  caused  by  the  severing  of 
important  arteries,  the  only  effective  means  is  the  ligature,  the 
application  of  which  sometimes  demands  expert  knowledge  and 
judgment.  Great  injury  may  be  done  by  unskillful  ligation.  In 
the  larger  vessels,  the  arteries,  veins,  and  nerves  may  be  within  the 
same  sheath,  which  is  but  an  infolding  of  the  fascia ;  and  there  may 
be  more  than  one  vein.  Before  ligating,  the  sheath  should  be 
opened  and  the  vessel  to  be  tied  dissected  out.  The  ligature  should 
be  passed  about  it,  and  fastened  with  a  square  knot  to  prevent 


288  ORAL    PATHOLOGY   AND   PRACTICE. 

slipping.  The  knot  should  be  drawn  firmly,  but  not  too  tight,  lest 
the  outer  coat  of  the  vessel  be  cut,  and  sloughing  and  secondary 
hemorrhage  be  the  result.  An  artery  should  not  be  drawn  out  of 
its  sheath  any  farther  than  is  necessary  to  allow  of  tying,  because  in 
so  doing  its  future  nutrition  may  be  interfered  with,  through  sepa- 
ration of  or  injury  to  the  vaso-motor  nerves. 

Immediate  or  mediate  compression  may  be  used  for  stopping 
the  flow  of  blood  temporarily  when  it  is  excessive. 

Immediate  compression  is  accomplished  by  packing  the  wound 
zvith  lint,  and  then  applying  a  compress  or  bandage. 

Mediate  compression  is  zvhen  pressure  is  made  iipon  the  artery 
betzveen  the  zvound  and  the  heart.  Any  firm  substance  is  placed 
over  the  artery,  and  then  a  bandage  or  tourniquet  is  twisted  very 
firmly  about  the  part  until  the  bleeding  is  controlled. 

The  control  of  bleeding  by  acupuncture  is  sometimes  neces- 
sary in  aged  persons,  the  muscular  coats  of  whose  arteries  are  too 
weak  to  withstand  the  ligature.  This  consists  in  transfixing  the 
tissues  with  an  acupuncture  needle,  and  then  winding  about  it  a 
ligature  in  such  a  manner  as  to  produce  local  compression. 

Aneurisms  may  be  formed  through  injuries  to  arteries,  when 
some  of  their  coats  are  divided  and  there  is  dilatation  of  those  which 
remain  unpunctured.  In  their  earlier  stages  aneurisms  may  be 
diagnosed  by  the  distinct  pulsations  within  them,  but  later  this 
may  be  masked  by  the  thick  felt  of  blood  coagulum  which  forms 
within.  A  tumor  in  the  immediate  neighborhood  of  an  artery 
should  be  opened  with  extreme  caution,  lest  it  prove  of  an  aneur- 
ismal  character. 

The  ligating  of  an  artery,  when  skillfully  done,  does  not 
deprive  the  tissues  dependent  upon  it  of  their  vascular  supply,  as 
sufficient  collateral  circulation  is  soon  established.  This  takes 
place  through  an  enlargement  of  the  communicating  and  anasto- 
mosing smaller  arteries  given  ofif  above  and  below  the  wound, 
until  they  are  sufficient  to  convey  the  volume  of  blood  originally 
carried  by  the  divided  vessel. 

A  wound  having  been  cleansed  and  irrigated,  and  the  hemor- 
rhage having  been  completely  controlled,  the  next  step  is  to  close  it. 
If  the  gaping  is  considerable,  it  may  be  necessary  to  sew  it  up. 
This  is  done  with  sutures  of  catgut  if  it  is  deep,  or  with  silk  if  more 
shallow.     The  stitches  are  made  with  suture  needles  of  differing 


TREATMENT   OF    WOUNDS.  289 

shapes,  which  may  be  passed  by  means  of  needle  forceps.  All 
ligatures  or  sutures  must  be  thoroughly  sterilized  before  using. 
The  depth  of  the  stitches  must  be  proportioned  to  the  depth  of  the 
wound.  If  this  is  considerable,  it  may  be  advisable  first  to  insert 
a  few  catgut  sutures  to  hold  in  place  the  deeper  tissues.  The  final 
closing  ones  are  always  superficial,  and  they  should  be  near  enough 
together  to  prevent  any  gaping  of  the  edges.  The  closing  stitches 
should  be  carefully  made,  so  that  there  will  be  no  drawing  of  the 
integument,  the  borders  of  the  wound  being  left  in  smooth  coapta- 
tion. They  are  to  be  removed  as  soon  as  there  is  sufficient  union 
to  prevent  the  separation  of  the  edges.  This  will  be  within  a  very 
few  days,  if  all  goes  well.  Sometimes  it  is  necessary  to  use  deep 
retentive  sutures  to  prevent  undue  tension  upon  the  closing 
stitches.  They  have  their  insertion  at  some  distance  from  the 
margin  of  the  wound,  and  each  end  is  attached  to  a  button,  so  that 
they  will  not  be  likely  to  cut  through  the  tissues. 

If  the  wound  has  become  infected  with  septic  organisms,  or  if 
there  is  good  reason  to  suspect  that  it  will  be  impossible  to  keep  it 
aseptic,  it  may  be  necessary  to  insert  a  drainage  tube  before  com- 
pletely closing  it.  This  may  be  of  sterilized  rubber,  or  of  decalci- 
fied bone;  or  it  may  be  only  some  strands  of  silk  or 
gauze,  carried  to  the  deep  portion  of  the  wound  and  allowed 
to  come  to  the  surface;  and  its  size  should  be  propor- 
tioned to  the  amount  of  probable  discharge.  The  drainage  tube 
ofifers  a  ready  means  of  escape  for  pus  or  sanious  matter,  secretions 
of  glands,  or  the  products  of  inflammation.  If  the  tube  penetrates 
to  a  cavity  of  the  body,  some  effective  means,  like  a  ligature  or  the 
insertion  of  a  safety  pin,  must  be  employed  to  prevent  its  being 
drawn  into  the  cavity.  To  retain  it  and  keep  it  from  slipping  out, 
it  may  be  held  by  the  external  dressings,  by  adhesive  strips,  or 
other  convenient  means.  The  drainage  tube  is  to  be  left  in  place 
as  long  as  there  is  a  necessity  for  its  presence.  Sometimes  it  is  of 
great  convenience  in  irrigating  or  washing  out  the  wound. 

The  final  dressing  of  a  wound  should  be  with  antiseptics. 
After  terminal  washing  and  cleansing  of  the  exterior  with  an 
antiseptic  fluid  the  surface  is  usually  dusted  with  aristol,  acetanilid, 
or  iodoform.  A  piece  of  antiseptic  gauze  is  then  superimposed, 
and  upon  this  sterilized  cotton  batting,  in  quantity  sufficient  to 
make  a  thick  pad.     The  wounded  organ  may  then  be  bandaged, 


290  ORAL    PATHOLOGY   AND    PRACTICE. 

and  placed  in  a  sling  or  support  if  required.  The  dressings  may 
be  removed  when  necessary,  but  should  not  be  disturbed  by  med- 
dlesome interference. 

Poisoned  wounds  that  are  of  a  serious  character,  such  as  the 
bites  of  venomous  serpents,  should  be  immediately  ligated  to  pre- 
vent the  spread  of  the  poison  in  the  blood,  and  then  be  thoroughly 
cauterized.  The  latter  may  be  effected  by  the  actual  cautery  or 
by  cauterizing  agents  like  silver  nitrate  or  chromic  acid.  An 
effectual  though  not  agreeable  way  is  to  burn  gunpowder  upon 
the  wounded  surface.  This  may  be  practicable  in  case  of  accidents 
when  no  other  cauterizing  agent  is  at  hand. 

The  after  treatment  of  wounds  consists  in  the  exercise  of  the 
most  watchful  care  to  avoid  septic  infection,  or  to  combat  it  when 
present.  All  dressings  must  be  kept  clean  and  in  place,  and 
changed  if  necessary  to  accomplish  this.  But  meddlesome  inter- 
ference must  be  avoided,  and  no  dressing  should  be  removed  unless 
there  is  good  cause  for  it.  When  the  organizable  lymph  has  been 
effused  it  must  be  protected  and  kept  aseptic.  Every  sanitary 
precaution  should  be  observed,  and  the  patient  sustained  with  a 
nourishing  diet.  A  wounded  limb  must  be  kept  quiet  and 
muscular  action  prevented,  except  so  far  as  motion  of  joints,  etc., 
is  required  to  prevent  ankylosis. 


CHAPTER    LXIII. 
EXCESSIVE  BLEEDING. 


There  is  nothing  in  dental  practice  that  is  more  alarming, 
especially  to  the  young  practitioner,  than  to  have  follow  an  opera- 
tion an  unusual  flow  of  blood  which  cannot  readily  be  checked. 
Too  many  lose  their  presence  of  mind  at  such  times,  become  con- 
fused and  distracted,  exhibit  this  in  their  manner,  and  thereby  alarm 
both  patient  and  attending  friends,  A  physician  is  perhaps  called, 
who  assumes  direction  of  affairs,  and  the  dentist  is  relegated  to  a 
subordinate  position.  As  a  consequence  he  is  humiliated  and  loses 
the  confidence  of  all  who  are  witnesses.  Exaggerated  accounts  of 
the  matter  are  circulated  from  mouth  to  mouth,  and  his  profes- 
sional reputation  may  thus  be  irretrievably  injured  in  the  commu- 


EXCESSIVE   BLEEDING.  29 1 

nity.  All  this  may  at  any  time  be  the  consequence  of  lack  of 
knowledge,  or  a  deficiency  in  professional  self-confidence.  In  any 
sudden  emergency  the  most  important  requisite  on  the  part  of  the 
doctor  is  self-possession,  and  the  entire  command  of  his  own 
powers. 

The  first  thing  to  consider  in  cases  of  hemorrhage  is  whether  it 
is  arterial,  venous,  or  capillary.  If  the  former,  the  blood  will  be  a 
bright  red,  and  will  issue  from  the  wound  in  jets,  synchronous  with 
the  heart-beats.  If  it  is  venous,  the  blood  will  be  darker  in  color 
and  will  well  up  continuously.  If  it  is  capillary,  there  will  be  a 
slow  oozing  from  the  edges,  which  will  appear  again  as  it  is  wiped 
away.  This,  while  the  least  alarming  in  appearance,  is  really  the 
most  threatening,  because  it  may  be  the  result  of  a  hemorrhagic 
diathesis. 

Arterial  bleeding  may  always  be  checked  by  ligation  of  the 
artery.  Usually,  however,  unless  the  vessel  is  an  important  one, 
it  will  be  sufficient  to  wipe  away  the  blood  with  a  sponge  until  the 
mouth  of  the  severed  vessel  is  found,  when  it  should  be  grasped 
with  a  pair  of  artery  forceps,  which  are  at  once  locked  upon  it.  In 
their  absence  the  mouth  of  the  artery  or  vein,  with  a  little  of  the 
surrounding  tissue,  may  be  seized  with  any  suitable  pliers,  and  the 
whole  twisted  and  pinched  until  the  coats  of  the  vessel  contract 
sufficiently  to  stop  the  bleeding.  Sometimes  a  waxed  silk  ligature 
passed  around  it  and  closely  tied  is  preferable. 

If  the  bleeding  is  from  the  socket  of  an  extracted  tooth  a 
pledget  of  cotton,  or  lint,  or  sponge  that  has  been  dipped  in  tannic 
acid,  or,  in  its  absence,  in  powdered  alum,  or  red  pepper,  or  in  a 
solution  of  iodine,  turpentine,  capsicum,  or  even  dilute  sulphuric 
acid,  should  be  closely  packed  at  the  bottom,  and  on  that  a  cork,  cut 
to  a  conical  form  that  shall  fit  the  socket,  should  be  placed  in  such  a 
manner  as  to  project  sufficiently  for  the  occluding  tooth  to  shut 
firmly  upon  it.  A  two-tailed  bandage  may  now  be  used  firmly  to 
press  up  the  lower  jaw  and  hold  the  cork  in  position.  This  should 
be  left  for  some  hours  at  least,  when  the  bandage  and  cork  may  be 
carefully  removed,  leaving  the  cotton  until  it  loosens  itself. 

If  the  bleeding  is  distinctly  venous  the  same  methods  may  be 
employed,  but  the  emergency  will  not  probably  be  as  great.  Arterial 
bleeding  will  be  certain  to  receive  attention,  but  the  smaller  veifis 
may  continue  open,  and  there  may  be  a  steady  loss  of  blood  for 


292  ORAL    PATHOLOGY   AND    PRACTICE. 

hours,  which  will  gradually  weaken  the  patient.  If  this  is  the 
case,  an  examination  should  be  made  to  determine  whether  the 
bleeding  is  from  the  small  veins  or  is  distinctly  capillary.  If  the 
former  the  points  of  its  issue  may  be  readily  determined,  but  if  it  is 
the  latter  there  will  be  a  slow  oozing  from  the  tissues  without  any 
distinct  point  of  exit. 

If  it  is  capillary  hemorrhage,  the  condition  will  demand  the 
greatest  care  and  cause  the  most  anxiety.  Strips  of  cotton  wet  with 
a  tannic  acid  solution,  or  a  ten  per  cent,  solution  of  antipyrine, 
or  with  one  of  the  other  hemostatics  named,  should  be  adjusted 
over  the  wound,  if  on  the  surface,  and  bandaged  to  place  if 
possible.  Monsell's  solution  of  perchloride  of  iron  should  not  be 
used  in  the  mouth,  nor  should  any  active  cauterants  be  employed. 
Tannic  acid,  in  doses  of  one  to  four  grains,  may  be  administered  in 
water  every  two  hours  in  extreme  cases.  Or,  of  the  aqueous 
extract  of  erigeron,  from  five  to  ten  grains  may  be  administered 
every  two  hours.  Or  from  fifteen  to  thirty  drops  of  tinct.  of  ergot 
may  be  given  every  hour  until  the  bleeding  ceases.  The  feet 
should  also  be  placed  in  hot  water  for  half  an  hour.  Veratrum 
viride,  as  an  arterial  sedative,  in  doses  of  two  to  five  drops  every 
two  hours,  will  frequently  prove  useful. 

In  the  so-called  hemorrhagic  diathesis  the  tendency  toward 
capillary  bleeding  is  due  either  to  some  abnormal  condition,  the 
result  of  a  distinct  dyscrasia,  or  to  a  lack  of  tone  in  the  system.  It 
seems  to  be  idiosyncratic  with  some.  When  either  of  these  is  the 
cause  it  may  demand  more  than  a  general  kngwledge  of  the  sub- 
ject, and  the  family  physician  should  be  called  to  learn  whether 
there  exists  any  special  cachectic  condition.  If  this  is  the  case  it 
will,  of  course,  be  turned  over  to  him.  Anemia,  purpura,  scrofula, 
typhoid,  and  other  diatheses  tend  to  induce  excessive  bleeding, 
and  in  their  presence  great  care  should  be  used.  If  there  is  any 
special  idiosyncrasy  the  patient  will  probably  know  of  it,  and 
should  warn  the  dentist  before  any  operation  is  commenced. 


,     •  1-RACTURES    AND   THEIR   TREATMENT.  2g$ 

CHAPTER     LXIV. 

FRACTURES  AND  THEIR  TREATMENT. 

Tpie  consideration  of  fractures  should  properly  be  taken  up  in 
connection  with  surgical  procedures.  But,  as  cases  of  injury  to 
the  jaw  and  head  may  at  any  time  fall  into  the  hands  of  the  dental 
practitioner,  this  work  would  be  incomplete  if  their  pathology  was 
not  in  an  epitomized  manner  given  some  attention.  More  than 
this  is  not  attempted. 

A  fracture  is  a  solution  or  rupture  of  continuity  in  bone  or 
cartilage.  What  wounds  are  to  soft  tissues,  such  are  fractures  to 
the  framework  of  the  body.  They  form  one-seventh  of  all  the 
injuries  to  which  human  beings  are  liable.  They  are  ten  times  as 
frequent  as  dislocations.  They  are  of  all  degrees  of  severity,  from 
the  mere  indentation  or  irregular  depression  of  a  flat  bone  to  the 
complete  comminution  of  long  bones.  The  character  of  the  frac- 
ture will  depend  upon  the  force  which  produced  it  and  the  shape  of 
the  bone  itself.  Thus,  in  irregular  bones  the  fracture  is  usually  a 
compression,  while  in  long  bones  it  is  likely  to  be  a  complete 
separation,  with  more  or  less  displacement  of  the  fragments. 

Fractures  may  be  produced  by  external  violence  or  by  internal 
muscular  action.  Probably  a  much  greater  proportion  of  them  are 
caused  by  the  latter  than  would  be  readily  imagined.  In  falling 
from  a  considerable  height  the  muscles  may  be  so  spasmodically 
contracted  as  to  break  the  bones  of  their  attachment  before  the 
individual  strikes  the  ground. 

The  strength  of  bones,  and  therefore  their  ability  to  with- 
stand injuries,  depends  upon  their  texture.  Compact  tissue  is 
stronger  than  that  which  is  cancellous,  and  the  bones  of  different 
individuals  greatly  vary.  So  also  does  the  strength  of  a  bone 
alter  with  the  physical  condition,  certain  diatheses  predisposing  to 
weakness,  until  perhaps  in  some  extreme  instances  they  yield  to 
comparatively  slight  muscular  exertion,  and  break  almost  spon- 
taneously. The  shape  of  bones  has  also  much  to  do  with  their 
strength,  the  long  and  flat  being  more  liable  to  fracture  than  the 
irregular. 

The  bones  of  males  are  stronger  than  those  of  females,  but 


294 


ORAL    PATHOLOGY    AND    PRACTICE. 


they  are  more  exposed  to  accident.  Age  has  much  to  do  with  the 
resisting  power  of  the  different  parts  of  the  skeleton,  those  of  older 
people  being  more  brittle.     Weak  points,  or  curves,  largely  deter- 


FiG.  95. 


^ 


y 


Bony  Ankylosis  of  the  Elbow  Joint. 


FRACTURES    AND   THEIR   TREATMENT.  295 

mine  the  course  of  fractures,  especially  when  they  are  the  result 
of  muscular  action. 

Fractures  of  the  bones  are  said  to  be  either  Simple,  Compound, 
or  Complicated. 

A  simple  fracture  is  one  in  which  the  skin  or  mucous  membrane 
is  not  ruptured,  and  there  is  no  serious  injury  to  the  investing  tissue. 

A  compound  fracture  is  one  in  which  there  is  a  communication 
through  the  skin,  or  exposure  of  the  hone  to  the  air,  with  the  pos- 
sibility of  infection. 

A  complicated  fracture  is  one  in  which  other  tissues  are  involved 
in  the  injury. 

Fractures  are  also  classed  by  surgeons  as  Complete  and  Incom- 
plete. 

A  complete  fracture  is  one  in  which  there  is  a  separation  of 
the  body  of  the  bone  into  two  or  more  fragments.  Complete  frac- 
tures may  be  divided  as  follows: 

A  Transverse  Fracture  is  one  that  is  at  nearly  right  angles  to 
the  axis  of  the  bone. 

An  Oblique  Fracture  is  one  that  is  at  an  angle  of  ten  or  more 
degrees. 

A  Longitudinal  Fracture  is  one  that  is  at  an  angle  of  more  than 
seventy  degrees. 

An  Epiphyseal  Fracture  is  a  fracture  of  the  cartilage  which  unites 
the  epiphysis,  or  extremity,  to  the  shaft  of  a  bone.  Of  course  it  can 
only  occur  in  young  persons. 

A  Mvdtiple  Fracture  is  one  in  which  the  hone  is  separated  into  a 
number  of  fragments. 

An  Impacted  Fracture  is  when  one  fragment  penetrates  another y 
thus  preventing  their  free  movement. 

A  Comminuted  Fracture  is  one  in  which  the  hone  is  shattered,  or 
separated  into  fine  particles. 

An  incomplete  fracture  is  when  there  is  not  an  entire  separa- 
tion of  the  body  of  the  bone,  but  either  it  stops  short  of  that  or 
consists  in  the  breaking  off  of  a  portion.  Incomplete  fractures  may 
be  classified  as  follows : 

A  Fracture  of  the  Apophysis  is  the  separation  of  that  process 
from  the  shaft. 

A  Detached  Fracture  is  the  separation  of  a  fragment,  as  by  a 
cutting  instrument. 


296  ORAL    PATHOLOGY   AND   PRACTICE. 

Fracture  of  the  Malleolus  is  a  separation  of  the  hammer-shaped 
head  of  a  hone,  the  body  or  shaft  remaining  intact. 

A  Green-stick  Fracture  is  what  its  name  indicates:  the  splintering 
of  a  hone  without  its  entire  separation.  This  is  necessarily  mainly 
confined  to  long  hones,  and  to  young  persons. 

A  Fissured  Fracture  is  the  opening  of  a  crack  in  one  plate  of  a 
hone,  as  in  certain  fractures  of  the  crania. 

A  Depressed  Fracture  is  when  a  dent  is  made  in  the  table  of  a 
hone,  a  part  being  thus  displaced  without  entire  separation. 

The  diagnosis  of  fracture,  although  usually  easy,  may  be  ex- 
ceedingly difficult.  The  symptoms  presented  are  both  objective  and 
subjective.     They  may  be  arranged  under  the  following  heads: 

History  of  the  predisposing  or  immediate  cause.  This  should 
always  be  carefully  inquired  into,  especially  if  the  force  seems 
inadequate  to  the  production  of  the  injury. 

Localised  pain  and  tenderness.  This  may  be  determined  by 
pressure  and  digital  manipulation. 

Crepitus^  or  Crepitation.  This  is  the  grating  of  one  fractured 
end  upon  another,  and  is  determined  by  careful  movements  of  the 
parts.  In  impacted  fractures  this  means  of  diagnosis  is  elimi- 
nated, and  hence  it  may  be  difhcult  to  arrive  at  a  conclusion. 

Abnormal  mobility.  It  is  sometimes  almost  impossible  to 
determine  this  in  the  neighborhood  of  joints,  unless  crepitus  is 
present. 

Consequent  deformity.  This  may  be  partially  or  completely 
masked  by  the  swelHng  consequent  upon  the  injury. 

Comparison  of  two  sides.  This  is  very  important  in  determin- 
ing the  deformity,  but  a  possible  asymmetry  may  lead  one  astray^ 
unless  caution  is  used. 

When  the  deformity  is  reduced  it  will  not  remain  so,  but  the  parts 
will  separate  and  reproduce  it.  This  will  distinguish  a  certain  class 
of  luxations  from  fractures. 

Anesthesia  is  sometimes  necessary  in  making  a  diagnosis, 
owing  to  the  resistance  of  muscular  action. 

Treatment  of  Fractures. 
Bones  very  readily  unite  when  their  injuries  are  properly 
treated.     Reduction   is   the   first   thing   to   be   accomplished.     If 
there  are  no  complications,  and  if  the  fractured  ends  are  firmly 


FRACTURES    AND    TJ£l<:iK    i  RliATMIiNT.  297 

held  in  apposition,  there  will  be  a  deposit  of  plastic  lymph — in  this 
instance  usually  called  provisional  callus — about  the  injured  ex- 
tremities. This  assumes  a  cartilaginous  form,  and  in  due  time 
ossifies  and  firmly  unites  the  fragments,  the  process  demanding 
from  four  to  eight  weeks.  There  will  necessarily  be  some  tem- 
porary enlargement  and  deformity,  which  will  greatly  depend  upon 
the  amount  of  displacement.  In  time,  as  the  newly  formed  tissue 
becomes  fully  organized,  the  projecting  portions  will  be  resorbed, 
and  the  irregular  surfaces  thus  made  more  symmetrical. 

Before  the  final  reduction  any  muscular  injury  must  be  at- 
tended to,  and  if  there  are  complications,  such  as  involvement  of  a 
joint  or  injury  to  a  contained  organ,  or  comminution  of  the  bone, 
these  must  be  looked  after. 

The  greatest  obstacle  to  reduction  and  retention  will  be  the 
muscular  contraction  consequent  upon  the  injury.  This  must  be 
controlled  by  traction  and  counter-traction.  A  steadily  applied, 
moderate  force  must  be  brought  to  bear  upon  the  muscles  until 
they  gradually  yield.  Violence  will  only  increase  the  contraction, 
but  a  gentle,  persistent  force,  like  that  of  a  weight,  will  after  a  time 
tire  the  muscles  out,  when  they  will  readily  give  way. 

Oblique  fractures  usually  need  only  extension  for  their  reduc- 
tion. Transverse  fractures  with  displacement  require  also  manipu- 
lation. 

When  reduction  is  accomplished,  the  parts  are  usually  held  in 
place  by  splints  or  bandages.  Absolute  immobility  is  not  required, 
as  slight  motion  is  beneficial,  owing  to  the  fact  that  it  is  a  stimulus 
to  functional  activity,  but  this  must  not  be  sufficient  to  interfere 
with  the  deposition  and  organization  of  the  provisional  callus. 

In  the  treatment  of  compound  fractures,  the  wound  must  be 
considered  as  an  open  one,  and  the  instructions  given  in 
Chapter  LXII.,  Treatment  of  Wounds,  should  be  kept  in  mind. 
Thorough  asepsis  must  be  secured  if  possible.  An  anesthetic 
may  be  administered  and  the  injury  thoroughly  explored 
for  the  removal  of  all  comminuted  fragments,  blood-clots, 
and  foreign  matter.  A  drainage  tube  may  be  inserted  if  desirable, 
and  the  wound  left  open  at  its  center. 

Delayed  union,  or  non-union,  may  exist  when  the  plastic  exu- 
date is  not  promptly  thrown  out,  or  being  deposited  is  not  organized. 
Perhaps  the  circulation  or  nutrition  is  impaired.     This  condition 


298 


ORAL    PATHOLOGY   AND   PRACTICE. 


should  be  attentively  looked  after.     The  ends  of  the  bone  may  be 
rubbed  together  if  necessary,  to  stimulate  functional  activity. 

Delayed  union  may  result  in  the  formation  of  a  "false  joint,"  or  a 
fibrous  union.  In  such  instances  it  will  be  necessary  to  break  this 
up,  and  perhaps  to  bore  the  ends  of  the  bone,  or  scrape  them,  to 
induce  a  new  osseous  formation. 

Fig.  96. 


Fibrous  Ankylosis  of  a  Joint. 


Non-union  may  be  the  result  of  a  neglect  properly  to  reduce  the 
fracture.  The  ends  of  the  bone  may  become  rounded  off  by  re- 
sorption and  the  medulla  be  closed.  The  remedy  in  such  in- 
stances is  to  open  the  seat  of  the  fracture,  saw  ofif  the  ends  of  the 
bone,  and  depend  upon  a  new  formation  after  reduction. 

In  fractures  of  the  long  bones,  shortening  is  likely  to  be  the 
result  of  muscular  contraction  and  the  overlapping  of  the  ends  of 
the  fragments.,  unless  extension  is  used. 


SriiCIAL    CASES    OF    FI^ACTL'UE.  299 

CHAPTER     LXV. 

SPECIAL  CASES  OF  FRACTURE. 

Fractures  of  the  nasal  bones  may  be  determined  by  the  deform- 
ity, by  the  infiltration  or  emphysema  of  the  investing  tissues,  by 
crepitus,  and  through  obstruction  of  the  nasal  passages  by  blood- 
clots.  They  are  not  dangerous  unless  the  injury  is  at  the  base, 
when  the  cribriform  plate  of  the  ethmoid  may  be  injured,  and  a 
shock  thus  given  to  the  brain.  The  adjustment  must  usually  be 
by  means  of  directors  or  needles  thrust  up  the  nostril,  and  the 
parts  are  held  in  place  by  adhesive  strips. 

Fig.  97. 


A  Simple  but  Effectual  Method  of  Wiring  the  Teeth  Together  for  the  Purpose 
OF  Reducing  a  Fracture. 

Fractures  of  the  superior  maxilla  and  of  the  alveolar  process 
may  be  met  with.  If  they  are  incomplete  and  there  is  no  special 
deformity  they  have  little  significance.  The  nasal  and  alveolar 
processes  are  frequently  broken.  The  former  may  be  a  complica- 
tion of  injuries  to  the  nasal  bones.  The  latter  may  be  broken  in 
careless  extraction  of  the  teeth.  It  very  readily  unites,  and  usually 
requires  little  attention  unless  a  small  fragment  is  displaced,  in 
which  case  it  should  be  removed. 

Fractures  of  the  body  of  the  superior  maxilla  may  result  from 
great  violence.  There  is  no  bone  which  so  readily  unites,  and  all 
that  is  usually  necessary  is  to  reduce  the  fracture  as  completely  as 


300  ORAL    PATHOLOGY    AND    PRACTICE. 

possible,  and  retain  the  parts  in  apposition  by  bandages  and  ad- 
hesive strips.  When  the  injury  is  considerable,  the  adjustment 
may  sometimes  be  made  by  getting  the  teeth  in  alignment,  and 
retaining  them  by  ligatures,  gold  bands,  or  even  an  artificial  palatal 
plate. 

The  antrum  may  be  involved  in  fractures  of  the  superior 
maxilla,  and  this  may  introduce  a  complication  that  may  embarrass 
the  treatment.  In  such  a  case  the  directions  given  in  Chapter 
XXXV.,  on  Diseases  of  the  Maxillary  Sinus,  should  be  observed. 

The  hemorrhage  in  fractures  of  the  maxilla  is  not  usually 
serious,  and  it  will  not  be  difficult  to  control. 

Fractures  of  the  inferior  maxilla  are  three  times  as  common  as 
those  of  the  superior.  This  is  because  of  their  increased  liability 
to  accident  through  their  greater  exposure.  The  fractures  are 
most  often  those  of  the  body,  although  the  ramus  may  be  the  seat 
of  the  injury. 

The  diagnosis  is  easy,  except  when  the  injury  is  to  the  coro- 
noid  process  or  the  ramus.  The  symptoms  are  pain,  deformity, 
mobility,  and  crepitus.  The  teeth  form  a  most  important  auxiliary 
in  both  diagnosis  and  treatment.  Observation  of  the  position  of 
the  jaws  and  the  occlusion  of  the  teeth,  if  the  latter  are  present,  will 
ordinarily  be  sufficient  to  determine  the  amount  of  injury  and  the 
best  method  of  reduction. 

The  treatment  of  all  such  cases  is  best  accomplished  by  the 
dentist,  because  he  is  familiar  with  the  normal  condition  of  the 
organs  involved,  and  he  has  the  mechanical  skill  to  construct  the 
appliance  which  will  best  reduce  the  displacement  and  retain  the 
fragments  in  proper  apposition.  Too  often  the  proper  function  of 
the  teeth  is  lost  through  lack  of  the  knowledge  how  to  secure  their 
proper  alignment,  or  so  to  retain  the  fragments  that  normal  occlu- 
sion will  be  secured  when  healing  is  complete. 

Various  forms  of  splints  have  been  devised  by  ingenious 
dentists  for  the  treatment  of  fractures  of  the  inferior  maxilla. 
Some  have  held  the  fragments  in  apposition  with  the  upper  jaw  by 
banding  the  opposite  or  occluding  teeth  on  each  side  of  the  line  of 
fracture,  and  then  holding  them  together  firmly  by  means  of  a 
connecting  screw  or  clamp. 

Various  devices  for  wiring  the  teeth  together  have  been  pro- 
posed. The  general  surgeon  has  in  the  past  mainly  depended  upon 
this  method  of  retention. 


SPECIAL  CASES  OF  FRACTURE.  30 1 

Skull  caps,  with  fixed  or  elastic  bandages  passing  around  the 
lower  jaw,  have  been  employed. 

Where  there  are  enough  of  teeth  in  each  jaw  to  serve  the 
purpose,  an  excellent  method  for  reducing  and  holding  in  place 
the  fragments  is  simply  to  place  around  convenient  teeth  silver 
wires,  and  then  twist  those  opposite  each  other  together  until 
the  teeth  are  in  correct  apposition  and  held  firmly  in  occlusion. 
The  twisted  ends  may  be  covered  with  small  rubber  tubing  and 
bent  down  closely,  to  prevent  their  lacerating  the  buccal  tissues. 
The  jaws  are  thus  held  together  until  union  has  taken  place. 
If  no  teeth  have  been  lost,  so  that  feeding  can  be  through  the 


Fig.  98. 


Swaged  Aluminum  Splint  to  be  Cemented  in  Position. 
Its  borders  between  the  teeth  can  be  pinched  together  so  as  to  hold  the  fractured  parts 
firmly  in  position.    The  swage  is  made  from  a  plaster  cast  that  has  been  sawed  apart  at  the 
points  of  fracture  and  afterward  properly  adjusted. 

vacancies,  it  is  always  possible  to  carry  sufficient  food  into  the 
mouth  through  the  space  posterior  to  the  molars,  liquids  being 
mainly  used.      (See  Fig.  97.) 

One  of  the  most  effectual  methods  is  the  employment  of 
some  form  of  the  interdental  splint.  An  impression  of  the  frac- 
tured jaw  is  taken  in  some  plastic  material,  without  any  attempt  at 
replacement  of  the  fragments.  A  cast  of  this  is  made  in  plaster  of 
Paris,  which  gives  a  counterpart  of  the  deformed  jaw.  Another 
impression  and  cast  of  the  occluding  jaw  and  teeth  is  secured.  A 
fine  saw  is  run  through  the  cast  of  the  broken  jaw  at  the  point  or 
points  of  injury,  and  the  pieces  placed  in  proper  apposition  with  the 
cast  of  the  superior  teeth,  when  they  are  fastened  by  running 
plaster  of  Paris  about  them.  They  are  placed  in  an  articulator 
and  a  wax  model  of  a  splint  is  made  for  the  lower  jaw  which  will 


302 


ORAL    PATHOLOGY    AND   PRACTICE. 


properly  occlude  with  the  teeth  of  the  upper  jaw,  so  that  mastica- 
tion may  be  possible  during  the  process  of  healing. 

The  wax  model  is  reproduced  in  vulcanite,  and  when  the  frag- 
ments of  the  broken  jaw  are  adjusted  to  it  they  may  be  retained  in 
various  ways.  In  the  case  of  one  such  fracture  of  the  jaw  of  a 
noted  pugilist  treated  by  the  author,  which  had  remained  unre- 
duced for  some  weeks,  nothing  more  was  needed  than  the  insertion 
of  four  gold  screws  through  the  outer  plate  of  the  splint,  which 
.  obtained  their  hold  in  the  V-shaped  space  between  two  teeth  that 
were  close  together.  Although  this  case  demanded  a  subsequent 
operation  from  the  outside  for  the  removal  of  comminuted  frag- 
ments, it  was  not  found  necessary  to  remove  the  splint  until  healing 

was  complete. 

Fig.  59. 


Method  of  Holding  in  Position  the  Parts  of  a  Jaw  Fractured  at  the  Symphysis. 

(Angle.) 

In  another  case,  one  of  fracture  of  both  the  upper  and  lower 
jaws  in  a  boy  of  fourteen,  the  splint  consisted  of  a  gutta-percha 
impression  of  each  jaw,  trimmed  to  proper  shape.  After  their  prep- 
aration, and  immediately  before  their  insertion,  the  occluding  sur- 
faces were  warmed  so  that  they  would  adhere  together  when  reduc- 
tion was  accomplished,  an  elliptical  opening  between  the  anterior 
teeth  being  made  for  the  purpose  of  feeding.  The  adjusting  of  the 
parts  and  the  insertion  of  the  splints,  with  the  necessary  band- 
aging, was  accomplished  under  chloroform.  The  whole  work,  in- 
cluding the  taking  of  the  impressions,  the  fashioning  of  the  splints, 
and  the  reduction,  occupied  less  than  an  hour,  although  three  very 
competent  physicians  and  an  accomplished  surgeon  had  vainly  kept 
the  boy  under  an  anesthetic  for  more  than  four  hours  previously. 
Their  failure  was  solely  due  to  their  inability  to  construct  a  splint 
that  would  hold  the  parts  in  apposition  when  they  had  the  different 


DISLOCATIONS    AND    SPRAINS.  3O3 

fractures  reduced,  and  not  of  course  to  any  lack  of  surgical  skill  or 
knowledge. 

The  judicious  and  ingenious  dentist  will  readily  devise  an 
appliance  that  will  be  sufficient  to  retain  the  fragments  in  any  form 
of  injuries  to  the  jaws.  No  two  cases  present  precisely  identical 
conditions,  or  require  the  same  treatment,  and  he  will  vary  his 
appurtenance  so  that  it  will  meet  the  required  ends. 

It  is  no  part  of  the  scope  of  this  work  to  give  instructions  for 
the  mechanical  manufacture  of  splints,  interdental  or  otherwise. 


CHAPTER     LXVI. 

DISLOCATIONS  AND  SPRAINS. 

A  Dislocation  is  the  complete  or  partial  separation  of  the  articu- 
lar surface  of  one  bone  from  that  of  another,  or  the  displacement 
of  an  organ  from  its  natural  position. 

That  which  will  most  frequently  be  met  in  the  practice  of 
the  dentist  is  the  luxation  of  the  lower  jaw.  This  may  occur  in 
extraction  or  in  other  operations,  and  not  infrequently  it  may  be 
spontaneous  and  happen  in  gaping  or  yawning.  Some  people  are 
liable  to  it  on  slight  provocation,  the  condyle  easily  slipping  out 
of  the  glenoid  fossa. 

Joints  or  articulations  are  movable  and  immovable  or  fixed. 

If  movable,  they  are  complex  in  their  structure  and  are  united  by 
flexible  ligaments. 

If  slightly  movable,  they  are  usually  connected  with  Hbro-cartilage,. 
which  is  tough,  elastic,  and  pliant. 

If  immovable,  they  are  connected  by  mere  membranous  sutural 
ligaments. 

Sometimes  the  union  of  fibro-cartilage  is  so  firm  that  only  a 
fracture  can  cause  displacement. 

The  ends  of  articulated  bones,  if  the  joint  is  a  movable  one, 
are  enlarged  and  made  up  of  compact  tissue,  the  lamellae  differing 
from  those  of  the  other  parts,  being  without  Haversian  canals. 
The  nutrition  thus  being  less  complete,  they  are  more  apt  to  die. 

Articular  cartilage  covers  the  ends  of  bones,  and,  as  has  been 
said,  fibro-cartilage  separates  certain  of  the  joints,  such  as  the 


304  ORAL    PATHOLOGY   AND   PRACTICE, 

vertebrae.  A  man  is  half  an  inch  taller  in  the  morning  than  at 
night,  because  during  the  day,  when  he  is  in  an  upright  position, 
the  interarticular  fibro-cartilage  becomes  compressed. 

A  ligament  is  a  hand  of  compact  membranous  tissue  connecting 
the  articular  ends  of  hones,  and  sometimes  enveloping  them  in  a  capsule. 
It  is  not  the  office  of  the  ligament  to  hold  the  bones  together; 
that  is  the  function  of  the  muscles,  the  ligament  merely  limiting 
and  restraining  the  motion,  preventing  it  from  going  too  far. 

The  synovial  membrane  is  a  short  niembranous  tube  inclosing 
the  joint,  attached  at  the  edges  of  the  cartilage,  and  secreting  the 
synovia,  or  synovial  fluid,  for  the  lubrication  of  the  joint. 

When  there  are  many  muscles  and  great  flexibility  is  de- 
manded, as  in  the  wrist,  there  is  very  seldom  a  dislocation. 

Dislocations  are  traumatic,  pathological,  or  congenital. 

Traumatic  dislocations  are  the  result  of  external  violence  or  of 
muscular  action.     They  are  by  far  the  most  frequent  of  any. 

Pathological  dislocations  are  the  result  of  the  destruction  of  a 
part  of  the  articidation  by  disease. 

Congenital  dislocations  are  those  in  which  some  essential  part 
of  the  joint  has  never  developed,  and  hence  they  are  irreducible. 

Dislocations,  like  fractures,  may  be  simple,  or  compound,  or 
complicated. 

A  simple  dislocation  is  one  in  which  there  is  displacement ,  without 
injury  to  any  tissue. 

A  compound  dislocation  is  one  in  which  there  is  a  wound  that 
exposes  some  part  of  the  articidation  to  the  air. 

A  complicated  dislocation  is  one  in  which  important  nerves,  blood- 
vessels, or  other  tissues  are  involved  in  the  injury..  Complicated  dis- 
locations are  fortunately  infrequent. 

The  symptoms  of  dislocation  are  much  the  same  as  those  of 
fracture.     They  are  as  follows: 

Deformity.  This  will  be  evident  from  the  unnatural  position 
of  the  bone,  and  from  the  tumor  which  will  be  the  result. 

Pain.  This  may  be  quite  severe,  and  it  will  be  located  at  the 
position  of  the  joint.  It  will  probably  be  of  a  dull,  sickening 
character,  and  it  is  worse  than  that  of  a  fracture. 

Rigidity.  This  will  arise  from  the  fixation  of  the  part.s,  the 
voluntary  movements  being  entirely  absent  or  very  much  limited. 

New  position  of  the  hone.     This  may  often  be  traced  through 


DISLOCATIONS    AND    SPRAINS.  305 

the  tissues  by  digital,  or  even,  in  some  cases,  ocular  examina- 
tion. The  axis  of  the  bone  is  altered  and  all  its  relations 
are  modified.  Usually  there  is  lengthening  or  shortening,  as  in 
fractures. 

Dislocations  are  differentiated  from  fractures  by  the  immo- 
bility of  the  former,  the  absence  of  crepitus,  and  by  the  general 
appearance,  the  character  of  the  pain,  etc. 

In  dislocations  there  is  usually  complete  fixation  with  no 
power  of  voluntary  movement.  In  fractures,  on  the  contrary, 
there  is  apt  to  be  abnormal  movement  which  is  not  under  volun- 
tary muscular  control. 

Dislocations  are  treated  first  by  reduction.  This  is  best 
secured  by  manipulation,  whenever  that  is  possible. 

If  the  ligaments  are  badly  torn  and  the  luxation  is  thus  com- 
plicated, manipulation  may  cause  exceeding  pain,  and  an  anesthetic 
may  be  necessary. 

Sometimes  in  old  dislocations  there  have  been  exudation  and 
partial  organization  of  the  product,  with  perhaps  more  or  less  of 
bony  ankylosis  (see  Fig.  95)  ;  or,  more  probably,  fibrous  anky- 
losis may  have  been  formed,  so  that  it  is  impossible  to  obtain 
reduction  without  surgical  help  (see  Fig.  96).  In  these  cases 
it  may  be  necessary  to  open  the  joint  and  break  up  the  union. 
This  must,  of  course,  be  done  under  the  strictest  antiseptic  pre- 
cautions. 

Dislocation  of  the  inferior  maxilla  may  be  unilateral,  involv- 
ing but  one  side,  or  what  is  more  frequent,  bilateral,  with  forward 
displacement.  It  consists  in  a  slipping  forward  of  the  condyle  from 
the  glenoid  fossa,  over  the  eminentia  articularis.  It  occurs  only 
when  the  mouth  is  widely  opened.  The  external  pterygoid  muscle 
becomes  violently  flexed,  and  draws  the  condyle  forward  upon  the 
surface  of  the  bone.  The  temporal  muscle  becomes  rigid,  and 
helps  to  hold  the  condyle  in  its  false  position.  The  interarticular 
cartilage  is  carried  forward  with  the  condyle,  but  the  capsular 
ligament  is  not  usually  torn.      (See  Fig.  100.) 

The  symptoms  of  luxation  of  the  inferior  maxilla  are  a  rigidity 
of  the  jaw,  with  inability  to  move  it  or  to  close  the  mouth.  There  is 
a  marked  projection  of  the  chin,  and  the  condyle  may  be  felt  for- 
ward of  its  normal  position.  If  it  is  unilateral  there  is  a  deviation 
of  the  jaw  toward  the  uninjured  side. 


3o6 


ORAL    PATHOLOGY    AND    PRACTICE. 


The  reduction  of  the  dislocation  is  effected,  by  supporting  the 
symphysis,  and  at  the  same  time  depressing  the  angles  of  the  jaw, 
the  object  being  to  carry  the  condyle  downward  and  backward 
until  it  will  slip  over  the  articular  eminence.  The  operator  should 
stand  in  front  of  the  patient,  and,  the  thumbs  being  protected  by 
wrapping  around  them  a  handkerchief,  the  jaw  is  firmly  grasped 
with  both  hands,  the  protected  thumbs  being  placed  far  back  over 
the  molar  teeth.  Then,  by  pressing  down  with  the  thumbs  and 
supporting  the  symphysis  with  the  ends  of  the  fingers,  the  jaw 
may  usually  be  carried  to  place,  the  condyle  slipping  into  the 
glenoid  fossa  with  a  distinct  snap,  and  the  jaw  closing  with  con- 
siderable violence. 

Fig.  100. 


Dislocation  of  the  Lower  Jaw,   showing  the  Anatomical  Relation  of  tiik  Parts. 

(After  Sir  A.  Cooper.) 

Sometimes  it  may  be  necessary  to  use  a  stout  piece  of  wood 
between  the  back  teeth  as  a  lever  to  carry  the  condyle  down  and 
back,  the  angle  being  supported  with  the  hand.  This  method  will 
be  found  especially  useful  in  unilateral  luxations.  Some  kind  of  a 
pad  should  always  be  placed  between  the  teeth  of  the  two  jaws,  to 
prevent  their  being  broken  with  the  violence  of  the  closure  when 
the  reduction  is  made. 

Dislocation  of  the  lower  jaw  backward  sometimes  occurs,  but 

only  as  the  result  of  great  violence,  and  is  necessarily  accompanied 

by  fracture  of  the  borders  of  the  fossa.     The  dislocation  in  this  case 

,:becomes  of  less  importance  than  the  other  injury,  and  its  reduction 

-is  subordinate  to  the  other  treatment. 


SHOCK — COLLAPSE.  307 

A  Sprain  is  a  self-reduced  dislocation,  with  consequent  soreness 
from  the  violent  strain  upon  the  muscles  and  tendons,  and  with  pos- 
sible laceration  of  the  ligaments  or  attachments.     It  is  characterized 

by  severe  pain,  much  increased  by  movement,  with  rapid  swelling 
and  heat  in  the  joint.  Sprains  are  usually  treated  by  either  hot 
fomentations  or  cold  applications,  whichever  seems  indicated. 
The  former  will  be  likely  to  bring-  about  resolution,  while  the  latter 
will  be  demanded  when  there  is  a  great  deal  of  heat  and  an  intense 
hyperemia.  If  the  swelling  is  very  great,  through  excessive  effu- 
sion, it  is  well  to  bandage  with  cotton,  and  to  secure  immobility  by 
means  of  a  plaster  of  Paris  bandage,  after  the  swelling  shall  have 
subsided. 


CHAPTER    LXVII. 
SHOCK— COLLAPSE. 


Shock  is  the  depression  that  is  caused  by  severe  injuries,  surgi- 
cal operations,  or  great  mental  disturbance.  It  is  the  result  of  a 
profound  impression  made  on  the  cerebro-spinal  axis,  either 
directly,  through  some  afferent  nerve,  or  through  the  circulation. 
It  may  be  reflex  and  slight,  like  the  tem.porary  faintness  wdiich 
soon  passes  away,  or  so  severe  as  to  induce  a  vital  depression 
that  is  almost  instantaneously  fatal.  It  has  already  been  shown 
that  it  is  not  the  bullet  in  the  heart  that  kills,  but  the  impression 
upon  the  whole  nervous  system  which  is  its  consequence.  In  such 
an  instance  the  shock  is  the  direct  result  of  the  impact.  But  no 
less  fatal  may  be  the  indirect  effects  of  a  mental  impression.  It 
is  related  that  the  janitor  of  a  medical  school  had  made  himself  so 
obnoxious  to  the  students  that  even  his  life  had  been  threatened. 
As  the  result  of  a  conspiracy  among  them  he  was  captured  one 
night,  conveyed  to  a  sepulchrally  draped  room,  shown  a  block  and 
ax,  and  informed  that  he  was  to  be  executed.  Amid  the  solemn 
and  impressive  surroundings  he  was  seized  by  the  masked  men, 
his  neck  bared  and  placed  upon  the  block,  when  the  executioner 
struck  with  a  towel  wet  in  ice-water.  The  victim  was  taken  up 
dead.  The  shock  was  as  complete  as  though  the  actual  ax  had 
been  used. 


308  ORAL    PATHOLOGY    AND    PRACTICE. 

There  is  a  wide  difference  in  the  susceptibility  of  different 
persons  to  shock.  Some  are  of  an  emotional  nature,  and  compara- 
tively slight  mental  impressions  of  a  depressing  kind  produce  pro- 
found effects.  Others  are  more  stolid  and  apathetic,  and  lose  their 
nervous  equilibrium  less  readily.  It  is  well  known  that  an  unim- 
portant mishap  will,  in  some  instances,  produce  fatal  effects,  while 
in  others  the  system  will  successfully  withstand  the  gravest 
injuries.  The  immunity  of  drunken  men  to  the  results  of  accident 
is  proverbial.  Their  intoxication  so  exalts  or  stupefies  the  nervous 
system  as  to  fortify  it  against  or  exempt  it  from  shock,  the  usual 
result  of  injury. 

The"  shock  that  is  caused  by  mere  mental  impression  is  more  fre- 
quent and  often  more  profound  than  that  produced  by  actual  vio- 
lence. Especially  is  this  the  case  with  nervously  susceptible  people. 
The  mere  sight  of  a  dentist's  instruments  too  ostentatiously 
paraded  may  induce  a  depression  and  shock  to  a  nervous  female 
that  will  be  absolutely  more  injurious  than  the  contemplated  opera- 
tion. Any  incivility  of  manner  or  unnecessary  roughness  of 
method  on  the  part  of  the  operator  may,  to  a  timid  child,  be  worse 
than  the  real  pain,  because  it  can  induce  a  more  profound  shock. 
Infants  suffer  less  from  shock  than  adults,  other  things  being  pro- 
portionally equal,  as  the  element  of  apprehension,  or  mental  im- 
pression, is  eliminated.  In  the  light  of  these  truths  it  is  easy  to- 
comprehend  why  the  gentle,  suave,  sympathetic  dentist  is  able  to 
perform  with  comparative  ease  to  the  patient  operations  that  another 
finds  absolutely  impracticable. 

It  is  because  of  the  limiting  of  the  primary  shock  that  opera- 
tions under  the  influence  of  an  anesthetic  are  possible  and  safe,  that 
otherwise  would  be  fatal.  The  beneficence  of  these  agents  and  the 
glory  of  the  discovery  of  anesthesia  is  not  confined  to  the  im- 
munity from  pain  which  they  give,  but  they  have  saved  lives 
almost  innumerable  through  their  making  feasible  operations 
that  before  were  impracticable. 

The  usefulness  of  prophylactic  remedies,  to  be  employed  before 
dental  or  oral  operations,  lies  in  thieir  ability  to  prevent  shock  to 
the  nervous  system,  either  by  stimulating  it  so  that  it  can  success- 
fully withstand  disagreeable  impressions,  or  so  stupefying  it  as  ta 
make  it  insensible  to  them.  In  either  case  the  primary  shock  is 
correspondingly  lessened  cr  inhibited.   The  entire  confidence  of  a 


SHOCK COLLAPSE.  3O9 

patient  once  secured,  especially  that  of  a  child,  the  nervous  system 
will  without  injury  undergo,  or  even  be  insensible  to,  pain  that 
tinder  other  circumstances  would  be  unbearable,  because  the 
deadly  influence  of  shock  is  avoided.  It  may  readily  be  conceived, 
then,  that  the  subject  is  of  paramount  importance  to  the  operative 
■dentist,  and  that  it  is  his  bounden  duty  to  study  it  with  care.  In 
this  connection,  the  remarks  upon  nervous  influence  in  the  chapter 
on  Hypersensitive  Dentine  will  be  found  useful. 

The  distinction  between  shock  and  collapse  is  one  not  easily 
made  plain,  nor  is  it  necessary  here  to  draw  a  fine  discriminating 
line.  It  is  sufficient  if  we  consider  shock  as  the  result  of  either 
mental  or  physical  violence,  while  collapse  is  the  final  conse- 
quence of  continued  exhaustion.  Thus  the  impact  of  a  bullet  may 
induce  shock,  but  the  slow  bleeding  that  may  succeed  it  will 
finally  end  in  collapse. 

Shock  may  not  only  be  the  result  of  different  kinds  of  injury, 
physical  or  mental,  but  it  may  assume  different  forms.  It  is  im- 
possible to  draw  a  clear  line  of  demarkation  that  shall  place  in 
separate  categories  all  those  which  are  possible,  but  for  con- 
venience they  may  be  classed  as  torpid,  excitable,  and  delayed. 

In  torpid,  or  apathetic,  shock  the  symptoms  may  be  almost 
■entirely  referred  to  vaso-motor  paralysis.  The  circulation  is  mate- 
rially modified.  There  will  be  a  pallor  of  the  skin  and  of  the 
mucous  membrane,  with  coldness,  especially  of  the  extremities, 
and  the  patient  may  be  covered  with  a  cold  perspiration.  The 
expression  of  the  face  is  changed  or  lost,  the  pupil  of  the  eye  is 
•dilated  and  does  not  respond  readily  to  light.  There  is  irregular- 
ity of  the  action  of  the  heart,  with  a  weak,  thready,  and  perhaps 
almost  imperceptible  pulse.  The  respiration  becomes  slower  and 
more  superficial.  There  may  be  partial  or  complete  insensibility, 
mental  inactivity,  and  loss  of  control  of  the  voluntary  muscles. 
There  will  be  depressed  bodily  temperature,  perhaps  to  be  followed 
by  a  corresponding  rise,  and  in  some  instances  nausea,  and  possibly 
vomiting. 

In  excitable,  or  erethistic,  shock  the  patient  is  restless,  irrita- 
ble, easily  disturbed,  perhaps  uncontrollable.  There  is  found  a 
disordered  pulse,  with  irregular  breathing  and  dilated  pupils. 
Notwithstanding  the  actually  depressed  condition,  there  will 
be  the  appearance  of  unnatural  activity.     The  sufferer  may  per- 


310  ORAL    PATHOLOGY    AND    PRACTICE. 

haps  exhibit  an  impatience  with  and  opposition  to  the  institu-. 
tion  of  the  proper  remedial  measures,  or  the  continuance  of  any- 
necessary  operation.  To  the  operative  dentist,  these  symptoms 
are  often  premonitory  of  a  more  profound  impression,  and  are  not 
to  be  disregarded.  Upon  their  appearance  he  should  use 
redoubled  care  to  avoid  further  nervous  injury,  and  should 
promptly  administer  an  anodyne. 

Delayed  shock  is  the  condition  in  which  the  symptoms  are  only 
manifested  some  hours  after  the  injury  or  nervous  impression  has 
been  received.  They  do  not  materially  differ  in  reality,  and  may 
be  of  either  the  torpid  or  the  excitable  character.  They  may  be 
the  result  of  a  slow  and  concealed  hemorrhage.  This  type  is  often 
observed  after  dental  operations  that  were  not  of  a  serious  nature, 
but  which  were  considerably  prolonged.  The  patient  probably  has 
not  incurred  any  material  harm,  aside  from  the  bodily  depression 
that  ensues,  and  the  character  of  the  symptoms  will  be  rather  of  the 
excitable  than  the  apathetic  kind. 

The  physical  condition  will  not  be  materially  different,  no 
matter  what  the  cause  of  the  shock  or  the  nature  of  the  early 
symptoms.  If  it  is  serious  the  torpid  state  will  gradually  deepen 
into  coma,  and  the  excitement  will  as  progressively  subside 
into  entire  insensibility.  The  bodily  heat  may  steadily  become 
less,  the  breathing  more  superficial,  the  pulse  weaker  and  more 
rapid,  until  death  closes  the  scene.  Sometimes  this  will  be  an 
unexpected  end,  the  injury  or  nervous  impression  seeming  totally 
inadequate  to  produce  it.  As  has  already  been  affirmed,  the  result 
often  depends  more  upon  the  physical  condition  of  the  patient,  and 
the  bodily  ability  to  resist  or  sustain  the  deadly  depressing 
influence,  than  upon  the  nature  or  extent  of  the  injury  itself. 


CHAPTER     LXVIII. 
TREATMENT  OF  SHOCK. 

The  treatment  of  shock  consists  in  the  institution  of  measures 
to  bring  about  a  reaction.  But  these  must  be  cautiously  approached 
if  the  depression  is  very  profound,  or  if  it  arises  from  or  is  accom- 
panied by  any  great  loss  of  blood.     There   is  danger  that  the 


TRKATMKNT    OF    SHOCK  3II 

reaction  may  be  too  great  and  exhaustive,  or  that  recovery  from 
the  syncope  or  coma  may  be  followed  by  a  fatal  return  of  the 
hemorrhage.  Hence,  in  case  of  accident  the  precise  condition 
should  be  determined  before  any  extreme  measures  are  attempted. 

Sometimes  great  difficulties  are  encountered  in  using  the  usual 
remedies.  This  is  especially  true  in  that  common  form  of  nervous 
shock  called  syncope,  or  fainting.  Consciousness  being  lost, 
perhaps  the  patient  cannot  be  made  to  swallow,  and  if  fluids 
are  forced  into  the  mouth  they  will  nr)t  Ije  taken  down  the 
esophagus,  but  may  go  into  the  trachea  and  cause  suffocation.  If 
the  shock  is  so  profound  that  the  circulation  is  arrested,  there  will 
be  little  use  in  attempting  hypodermic  medication;  and  if  the 
breathing  is  suspended,  inhalations  of  volatile  stimulants  will  be 
impossible.  There  will,  of  course,  be  cerebral  anemia,  and  this 
should  be  at  once  combated  by  laying  the  patient  in  a  recumbent 
position,  with  the  head  as  low  as  the  rest  of  the  body,  or  even 
lower.  All  obstruction  to  a  free  circulation,  like  clothing  that  is 
too  tight  or  a  violently  flexed  position  of  any  limb,  should  be 
remedied.  The  lower  extremities  may  be  raised,  and  pressure 
used  to  press  the  blood  out  of  them  toward  the  head.  If  there  is 
blueness  of  the  lips,  it  may  indicate  that  the  head  is  too  low,  or 
that  there  is  some  obstruction  about  the  neck. 

As  soon  as  possible,  warm  stimulating  drinks  should  be  given, 
such  as  dilute  whiskey  or  brandy.  Volatile  stimulants  may  be 
applied  to  the  nostrils,  such  as  ammonia,  nitrite  of  amyl,  etc.,  but 
care  should  be  observed  to  avoid  their  being  so  unduly  strong,  or 
so  persistently  applied,  as  to  cause  suffocation.  If  the  body  is 
cold,  external  heat  should  be  applied  by  wrapping  the  patient  in 
hot  blankets,  or  by  laying  bottles  filled  with  water,  not  too  hot,  in 
the  axillae  and  about  the  body.  Chafing  the  extremities  should  not 
be  resorted  to  until  consciousness  has  returned,  lest  it  draw  away 
the  blood  from  the  head,  where  it  is  most  wanted. 

Artificial  respiration  should  be  used  if  tlie  breathing  is  sus- 
pended and  is  not  readily  resumed.  This  may  be  continued  as  long 
as  is  necessary,  but  it  should  not  be  violent.  Every  precaution 
should  be  taken  to  avoid  the  deepening  of  the  shock.  It  is  need- 
less to  say  that  in  the  unconsciousness  resulting  from  drowning, 
the  violent  rolling  of  the  body  upon  a  barrel  or  other  object  is  the 
surest  way  to  extinguish  whatever  of  vitality  may  remain. 


312  ORAL    PATHOLOGY   AND    PRACTICE. 

If  the  Stomach  will  not  retain  remedies,  or  if  the  patient  can- 
not swallow,  stimulating  drinks  may  be  administered  as  enemas, 
and  alcoholic  dilutions,  or  strong  coffee,  with  carbonate  of  am- 
monia, etc.,  will  be  almost  as  useful  as  when  given  by  the  mouth. 

Hypodermic  medication  is  very  useful  when  the  circulation  has 
been  maintained  or  restored.  The  activity  of  the  heart  may  be 
stimulated  by  strychnine  and  digitalis.  The  respiration  may  be 
strengthened  by  atropine.  These  remedies  should  be  given  in 
large  doses.  Park  recommends  that  in  serious  emergencies  there 
may  be  given  in  one  hypodermic  injection  one  c.c.  of  tincture  of 
digitaHs,  with  one-twentieth  of  a  grain  of  strychnine  and  one- 
hundredth  of  a  grain  of  nitro-glycerine.  This  to  be  repeated  as 
often  as  necessary,  or  digitalis  alone  may  be  administered  at  fre- 
quent intervals. 

In  case  the  shock  takes  the  form  of  extreme  nervous  excitement, 
anodynes  should  be  given.  Opium,  in  the  form  of  morphine  sul- 
phate, is  the  most  effective,  and  one-eighth  to  one-quarter  of  a 
grain  may  be  administered  hypodermically.  The  patient  should 
be  kept  as  quiet  as  possible  until  reaction  is  complete. 

When  the  shock  is  due  to  great  loss  of  blood,  as  from  tooth 
extraction,  a  saline  solution,  consisting  of  sterilized  water  looo 
parts,  ammonium  carbonate  i  part,  and  common  salt  6  parts,  may 
be  slowly  injected,  the  nearer  to  the  place  of  injury  the  better. 

The  hypodermic  syringe  should  always  be  kept  in  order,  and 
be  thoroughly  sterilized  before  being  used.  The  proper  remedies 
may  be  obtained  in  tablet  form,  ready  prepared  for  making 
solutions.  The  operator,  before  using  the  hypodermic  solution, 
should  see  that  no  air  is  in  the  barrel,  whence  it  may  be  driven 
into  the  circulation.  This  may  be  determined  by  holding  the 
point  of  the  syringe  up  after  filling,  and  expelling  the  air  by 
means  of  the  piston. 

Of  course,  every  operation  is  inhibited  during  the  existence  of 
shock.  It  matters  not  what  form  it  may  take,  whether  that  of 
increasing  lethargy  or  growing  excitement,  the  attention 
must  at  once  be  given  to  securing  recovery.  If  indications 
of  hysteria  are  observable,  that  may  be  one  of  the  symptoms 
of  excitable  shock,  and  the  patient  should  be  given  an  anodyne 
and  placed  in  a  recumbent  position  in  a  quiet  place,  the  operation, 
if  it  be  dental,  not  to  be  resumed  until  another  day. 


TREATMENT    OF    SHOCK.  313 

No  one  suffering  from  any  form  of  shock,  the  result  of  an  oral 
operation,  should  be  allowed  for  a  moment  to  remain  in  the  operat- 
ing chair,  as  the  recumbent  position  is  the  first  essential.  This 
does  not  seem  to  be  properly  appreciated  by  dentists.  The  extrac- 
tion of  teeth,  especially  when  an  anesthetic  is  administered,  can  be 
much  better  accomplished  when  the  patient  is  lying  down.  A 
couch,  specially  adapted  to  the  purpose,  should  be  provided  by 
those  who  give  anesthetics  for  the  extraction  of  teeth.  The  danger 
from  administration  is  very  materially  lessened,  while  convenience 
in  operating  is  proportionately  increased.  The  couch  should  be 
about  the  height  of  a  common  table,  and  only  wide  enough  easily 
to  hold  the  patient.  Standing  on  either  side  for  upper  teeth,  and 
at  the  head  in  extracting  lower  ones,  the  operator  has  much 
better  command  of  the  situation  and  is  less  liable  to  fracture  tooth 
or  alveolus,  while  the  chances  of  dropping  a  fragment  into  the 
trachea,  or  of  choking  the  patient  with  blood,  are  very  materially 
lessened.  Recovery  from  anesthesia,  and  from  the  shock  conse- 
quent upon  the  operation,  are  much  more  prompt  and  satisfactory. 
No  general  surgeon  would  for  a  moment  even  consider  the  ques- 
tion of  operating  in  any  case  with  the  patient  sitting  up.  Dentists 
should  change  their  methods,  and — at  least  in  operations  involving 
the  administration  of  anesthetics  and  the  extraction  of  a  number 
of  teeth — adopt  a  position  that  is  surgically  more  appropriate. 


INDEX. 


Abrasions  and  erosions  of  teeth,  233. 
Abscess,  blind,  121. 
chronic,    125. 
discharging,    122. 
incipient,   121. 
-i.'s.   ulcer,   117. 
Acid  reaction  in  tooth  erosion,  235. 
All  growth  by  alternate  periods,   74. 
Aluminum    splint,    301. 

Alveolar  abscess,  abortive  treatment  of,  130. 
definition  of,   117. 
.suppuration   of,    when   to    be   prompted, 

131- 
symptoms   of  formation   of,    129. 
treatment    by    absorption    of    remedies, 

133- 
treatment   from   outside,    133. 
Anemia  and  plethora,  28. 
Aneurisms,  288. 
Anesthesia  vs.  analgesia,   155. 
Animals  can  assimilate  nothing  except  the 

organic,  7. 
Ankylosis    of    teeth    in    sockets    not    at    all 

probable,  245. 
Antacids  in  chemical  erosions,  237. 
Antiseptic  formulse  for  caries,  loi. 

precautions,    importance  of,   24. 
Antiseptics,  list  of,  21. 

usually  germicides,   19. 
Antral  disease,   early  symptoms  of,    166. 

treatment  of,    167. 
Antrum  a  resonant  chamber,   161. 
drainage  tubes  in,   169. 
diseases   of,    principally  catarrhal,    163. 
foreign  substances  in,  164. 
septa  dividing,  171. 
varies  in  size  and  shape,   161 
Articulations,   classification   of,   303. 
Asepsis,  essential  in  plantation,  239. 
Auscultation  and  percussion,  269. 

Bacteria,   self-limiting,   14. 

Benign  and  malignant  tumors,  comparative 
symptomatology   of,    188. 

Bleaching   discolored  teeth,   226. 

Bloodvessels  of  pulp  without  usual  muscu- 
lar coats,  104. 

"Brow  ague"  of  malarial  origin,  153. 


Cachectic  conditions,  36. 
Cancers,    malignant   growths,    185. 
Carcinoma,   186. 

Caries  of   implanted   teeth   not   unlike   ordi- 
nary dental  caries,  243. 

of  alveolar  process,  194. 
difl'ers  from  bone  caries,   194. 
treatment  of,  197. 
Causes  of  sensitive  tooth  tissue,  105. 
Cauterization  of  fistulous  tract,   132. 

of  wounds,  290. 
Cementum  a  modification  of  bone,  96. 
Chancre  the  primary  syphilitic  sore,  251. 
Chancres  in  the  oral  cavity,  265. 
Chancroid  not  constitutional,  261. 
Chancroids,    multiple,    auto-inoculable,    pro- 
duce no  oral  lesions,  262. 
Cholera  bacillus,  20. 
Classification  of  tumors,  183. 
Coagulation  of  dentinal  fibrillse,  213. 
Cocain  poisoning,  278. 
Condylomata  of  syphilis,  260. 
Contamination   by   bacteria,   23. 
Cyst,  definition  of,   175. 
Cysts,  classification  of,  177. 

treatment  of,   181. 

where  developed,   176. 

Death  merely  cessation  of  function,  5. 

Death-rate   percentages,   72,  78,   79. 

Defects   in   enamel,   acquired   or   secondary, 

233- 

congenital,   227. 

when, congenital  cannot  be  pathological, 
228. 
Delayed  or  non-union  in  fractures,  297. 
Dental  caries,  early  theories  concerning,  90^ 

in  animals,  87. 

medicinal  treatment  of,  99. 

Miller's  demonstration,  91. 
theory,   92. 

not  of  modern  origin,  87. 

result  of  infection,  93. 
Dental  pulp  not  normally  sensitive,   102. 

without  lymphatics,   106. 
Dentigerous  cysts,   180. 
Dentine  a  modification  of  bone,  96. 
not  normally  sensitive,   102. 


315 


3i6 


INDEX. 


Dentition,  appearance  of  gums  in  disturbed, 
82. 
disturbances    of,    due    to    reflex    nervous 

action,  70. 
general  considerations,  (>•;. 
natural  appearance  of  gums'  in,  82. 
not    the    principal    cause    of    high    death- 
rate  among  children,  71. 
period  of,  a  transitional  one,  68. 
real  disturbances  in,  84. 
due  to  reflex  nervous  action,  85. 
lancing  of  gums  in,  86. 
Denudation    a    cause    of    sensitive    dentine, 

208. 
Denudation  caries  of  alveoli,   195. 
Digestive  disorders  not  due  to  teething,  74. 
Diphtheria,    bacillus   of,    2.^. 
Discoloration  not  usual  in  living  teeth  be- 
yond superficial  deposits,  225. 
Discolored  teeth,  causes  of,  226. 

general    considerations,   225. 
Dislocation,  definition  of,  303. 
Dislocations,   classification  of,  304. 

reduction  of,  305. 
Drainage  in  necrosis,   203. 
Drainage  tube  in  wounds,  289. 
Dressing  of  wounds,  289. 

Edentulous  jaws,  232. 
Enamel,  its  character,  98. 

only   hard    structure   not    protected   from 
exposure,  97. 
Epithelioma,   186. 
Epulitic  tumors,    189. 
Erosions  and  abrasions  of  teeth,  zz-^. 

may  be  the  result  of  acid  secretions,  236. 

not  the  effect  of  wear,  235. 
Eruptive   diseases   as  a  cause  of  imperfect 

enamel,  230. 
External     treatment     of     alveolar     abscess, 

133- 
Extraction  and  replantation,  238.      , 

in  necrosis  may  be  injudicious,  201. 

recumbent  position  in,  313. 


Facial  neuralgia,  definition  of,  150. 

paralysis,   definition  of,   154. 
Faradic  current  in  paralysis,  157. 
Fermentation,   alcoholic  and  acetous,   13. 

definition  of,  9. 

essentials  for,  10. 
Ferments,  organized  and  unorganized,  9. 

segmentation,  gemrnation,  and  fission,  10. 

spore  formation  in,  11. 
Fibrous    ankylosis,    "false   joint,"   298. 
First  intention,  healing  by,  40. 


Foraminal    opening    not    always    a    simple 

operation,    113. 
Formation  of  dentine,  207. 
Frontal  sinus,  its  degenerations,   173. 

opening    of,    174. 
Function,   definition   of,   i. 

in  the  new-born  infant,  75. 
Fungi,  aerobic  and  anaerobic.  13. 

classification  of,  5. 

obligate  and  facultative,   13. 

pathogenic,  saprogenic,  and  pyogenic,   14. 

their  office,  4. 
"Fur"  coating  of  the  tongue,  279. 

Gangrene,  44. 

Garretson's  experftnents  with  acids  in  caries 

and  necrosis,  196. 
Gentle  hands  and  sharp  instruments  in  ex- 
cavating  sensitive   dentine,   215. 
Germicides,    disinfectants    and    deodorants, 

19. 
Glossitis,  63. 

in  syphilis,  266. 
Granulation  of  food  in  infants,  "jii. 

or  second  intention,  41. 
"Green   stain,"    136. 
Gum  appearances  in  diagnosis,  280. 
Gums  or  gingivse  inflamed,  50- 

inflammation  of,  due  to  lack  of  care,  52. 

tissues  of,  50. 

Healing  "from  the  bottom,"  285. 

of  wounds,  285. 
Hemorrhage,   arterial,  venous,  or  capillary, 
291. 
excessive,  290. 
from  wounds,  287. 
Hemorrhagic  diathesis,  292. 
Hereditary  or  congenital  syphilis,  262. 
Homologous  and  heterologous  tumors,  183. 
Hutchinsonian    teeth,    262. 

not  always  pathognomonic,  264. 
Hypercementosis  presents  no  special  symp- 
toms, 222. 
sometimes    accompanied    by    osteophytes, 

222. 
the  analogue  of  hyperostosis,  222. 
Hyperemia  and   ischemia,  29. 
Hypersensitive   dentine,    general   considera- 
tions, 205. 

Impacted  teeth  a  cause  of  necrosis,  199. 
Implantation  an  accepted   method  of  prac- 
tice, 241. 
Induration  of  exudate,  39. 
Indurations,   135. 
Infection,  how  carried,  23. 


TNDEX. 


317 


Inflammation    a    destructive    process,    27. 
definition  of,  28. 
early  stage  a  hyperemia,  27. 
only  one  distinct  form  of,  26. 
predisposing  and  exciting  causes,  31. 
result  of  irritation,  28. 
symptoms  of,  34. 
termination  of,  46. 
by  resolution,  48. 
by  suppuration,  49. 
Infundibulum    may    discharge    in    antrum, 

i6s. 
Injudicious  feeding  of  infants,  ^^,  80.  - 
Insalivation,  i. 
Interdental   splint,  301. 
Involucrum   in   necrosis,   201. 
Irritation  makes  pulp  and  dentine  sensitive, 
104. 

KowARSKi's  paste  for  retaining  loose  teeth 
in  position,  241. 

Lancing  of  the  gums,  86. 
Leucocytes,  ameboid  forms,  17. 

changes  in,  37. 

Metchnikofi's  theory,   17. 

number  increased  in  inflammation,  38. 
Leucoplakia  of  syphilis,  261. 
Ligatures  for  holding  teeth  in  position,  241. 
Living  portions   of  bone  subject  to   inflam- 
matory conditions,   191. 
Localized  gingivitis,   144. 
Luxation  of  inferior  maxilla,  305. 

Malnutrition,  3. 
Massage  in  paralysis,   157. 
Matter,  general  classification  of,  4. 
"Mechanical   abrasion,"   234. 
Membrane  lining  antrum,  162. 
Mental  shock  most  profound,  308. 
Mercury  a  specific   in   syphilis,   254. 
Method   of   attachment   of   implanted   teeth, 

243- 
Mucous  plaques  or  patches,  257. 
Mummified   pulps,   120. 

Necrosis,  45. 

Necrosis,    an   analogue    of    gangrene,    19S. 

an   indication  of   debility,    198. 

causes  of,  199. 

diagnostic  signs  of,  201. 

treatment,    local,    operative,    and    general 
202. 
Neuralgia,  treatment  of,  153. 
Neuralgias,    symptoms    of,    151. 


New  pericemental  formation  in  case  of  im- 
plantation,  244. 

No  line  of  demarkation  between  normal 
and    hypertrophied   cementum,   224. 

Noma,  or  cancrum  oris,  56,  59. 

Normal  dentine  insensitive,  206. 

Nourishment  of  bone,  190. 

Nutrition   changes   in   tooth   tissues,    159. 

Obtunding  sensitive  dentine,  211. 

Odontoblasts  found  within  the  pulp,  216. 

Odontomata,  classification'  of,   179. 

Opening  the  antrum,   168. 

Operations   inhibited   during   shock,   312. 

Operative  measures  in  necrosis,  204. 

Oral  syphilitic  lesions  dangerous,  249. 

Organization   of  tissue,   42. 

Osteitis,  or  inflammation  of  bone,   191. 

always    a    result    of    periosteal    inflamma- 
tions, 200. 

treatment  of,    193. 

Papain  as  a  pulp  digester,  222. 
Paralysis    may   be   loss    of    tactile    sense   or 
insensibility  to  pain,  155. 
of  fifth  and  seventh  nerves,  155. 
Pathology,  definition  of,  2. 

oral,  2. 
Percussion   in  articulation,   269. 
Pericemental  abscess,   118. 
Pericementitis,     comparative     symptomatol- 
ogy of,    115. 

its  character,  111. 
Pericementum,  a  vascular  organ,   iii. 

separated  in  alveolar  abscess,  127. 
Phanerogams  and  cryptogams,  7. 
Pharyngitis  in  cleft  palate,  62. 
Pharynx,   definition  of,   61. 
Physical  diagnosis,  importance  of,  268. 
Physiology,  definition  of,  2. 
Plantation  of  teeth,  238. 
Plastic  exudate,   39. 
Pockets  in  the  alveolus,   146. 
Pregnancy,   dental   caries  in,    159. 
Prophylactics  in  dental  operations,  214. 
Proud  flesh,  285. 
Pulp  chamber,  opening  of,   120. 

capping,   when   interdicted,   106,    no. 

derives    its    blood    supply    from    the    peri- 
cementum,  III. 

digestion,  222. 

disinfection,  131. 

infection,  methods  of,  121. 

stones  in  substance  of  pulp,  217. 

without  usual  absorbents,   106. 
Pulpitis,    comparative    symptomatology    of, 
IIS. 


3i8 


INDEX. 


Pulpitis,  general  character  of,  ic2. 
successive  stages  in,  no. 
treatment  of,  io8. 
Pulse  and  condition  of  arteries,  zyz- 
definition  of,  269. 
different  kinds  of,  271. 
differs    with    individuals    and    conditions, 

269. 
method  of  taking,  270. 
rate  at  different  ages,  270. 
readings  depeijd  on  force  of  heart,  273. 
sphygmographic  tracings,   271. 
where  best  taken,  270. 
Pus,  composition  of,  22,  43. 
diff'erent  kinds  of,  44. 
may  be  discharged  at  a  distance  from  seat 

of  abscess,  127. 
must  be  evacuated,  49,  124. 
Pustular   eruptions   of   syphilis   modified   in 

the  mouth,  258. 
Pyorrhea  alveolaris,  definition  of,   141. 
in  domesticated  animals,    142. 
etiology    of,    not   positively    determined, 

142. 
of  three  distinct  kinds,  144. 
uric  acid  diathesis  in,  143. 


Ranula,  a  retention  cyst,  178. 
Reduction   of  fractures,  293. 
Removal  of  enamel  deposits,   147. 
Resection     of     inferior     dental     artery     not 
necessarily   fatal    to    vitality    of    pulp, 
114.  ' 

Resistive  power  of  function,  16. 

experiments   in,    17. 
Resolution,     a     building     up     and     tearing 
,  down,   40. 

Resorption  and  osteoclasts  in  cases  of  plan- 
tation of  teeth,  246. 
Respiration,   definition   of,  273. 
either  abdominal  or  thoracic,  274. 
in  diseased  conditions,  275. 
in  normal  conditions,  274. 
-Respiratory  murmurs,   275. 
classification  of,  275,  276. 
rales,  276. 
Revivification   of  dead  tissue  impossible   in 

plantations,   243. 
-Root  filling  need  not  go  beyond  foraminal 

delta,  134. 
Root  filling,  when  permitted,  132. 
Roots  of  teeth  penetrating  antrum,  163. 


Salivary  calculus,   formation  of,   137. 
Sarcoma,    185. 


Secondary    dental    formations    in    animals, 
218. 
pockets  in  alveolar  abscess,  127. 
pulp  formations,   true   dentine,  216. 
Selective  action  of  acids  in  caries,   196. 
Sensitive  dentine,  its  causes,  207. 

point  near  apex  of  root,   134. 
Septic   condition,    18. 

indications  of,  129. 
Sequestrum  in  necrosis,  201. 
Serumal   calculus,    138. 

distinctly  irritating,   139. 
formation  of,  139. 
Shock,   definition   of,   307. 
different  forms  of,  309.  , 

the    result    of    direct    or    reflex    nervous 

action,  30. 
treatment  of,  310. 
"Smoker's  patches,"  266. 

So-called   diseases    of   dentition   confined   to 
a  few  months  of  the  year,  tj. 
treatment   of,   81,   83. 
Sprain,    definition   of,   306. 
Stomatitis,   aphthous,    55. 
follicular,  54. 
treatment  of,  56. 
ulcerative,  55. 
Suppuration,  22,  43. 

when  to  be  encouraged,  131. 
Susceptibility  to  shock,  307. 
Sympathetic    disturbances,    general    consid- 
erations,   158. 
Syphilides  or  syphilodermata,  255. 
macular,   papular,   and  pustular,  256. 
of  the  mouth,  257. 
Syphilis,  appearance  of  chancre  in,  253. 
care  in  diagnosing,  251. 
chancre  rarely  suppurates,  254. 

usually  single,  254. 
definition  of,  250. 
general  considerations,  246. 
lymphatic  glands  affected  in,  254,  258. 
mercurv  a  specific  in,  254.  ■■ 

not.  auto-inoculable,  254. 
only  to   be   diagnosed   by   clinical   history 

and  grouping  symptoms,  268. 
period  of  incubation  of  secondary,  255. 
of  incubation  of  tertiary,  259. 
of    incubation    of    primary,    252. 
readily  yields  to  treatment,  251. 
secondary  stage,  255. 

period  of  incubation,  255. 
tertiary  form  of,  259. 

period  of  incubation,  259. 
the  chancre  single,  254. 
Syphilitic    discharge    sometimes    non-infect- 
ive,  249. 


INDEX. 


319 


Syphilitic  gumma  and  tubercle,  260. 
virus  intensely  infective.  248. 

Teeth   are  living   organs,   94. 

chemical  composition  of,   95. 

congenitally  without  enamel,  229. 

modifications  01  bone,  94. 

■with,  congenitally  imperfect  enamel,  230. 
Tents  and   plugs   in  antrum,   170. 
Test  for  success  of  an  operation,  208. 
Third  intention,  healing  by,  43. 

variety  of  pyorrhea,   149. 
Thrush  in  children,  56. 

Tongue,  appearance  of,   in  health  and  dis- 
ease, ^4. 

in  health,  279. 

injuries  of,  from  the  teeth,  66. 
Tonsillitis,  63. 

Tooth  tissues  of  organic  origin,  98. 
Treatment  of  alveolar  caries,   197. 

of  vv^ounds,  285. 
Tumors  or  neoplasms,  182. 


Ulcer  distinguished  from  abscess,  117. 

V'aso-motor   nerves,   32. 
Vegetable    alone    can    organize    the    inor- 
ganic, 6. 
Vitiated  secretions  in  sensitive  dentine,  209. 
Von   Recklinghausen's  theory,  39. 

Wandering  cells   of   Von   Recklinghausen, 

39- 
White  deposit,  135. 
Wounds,  classification  of,  283. 

definition   of,  282. 

succeeded  by  shock,  282. 

Yeast  fungus,   12. 

Zone  of  infected  dentine,  92. 
Zymotic  diseases,  15. 


B27 

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